BLS Rig Check Form
Please complete all fields below. If you require immediate re-stock assistance contact your duty officer.
Ambulance *
Date *
MM
/
DD
/
YYYY
Next Oil Change Mileage *
Any Damage To Ambulance *
Fuel Level *
Cab Equipment *
Required
Vehicle Lights/Emergency Warning Devices *
Required
Exterior Compartments *
Required
On-Board O2 PSI *
AED / ZOLL *
Required
AED Adult Pads (min 2) *
Required
AED Pediatric Pad *
Required
Portable Suction *
Required
Blue Jump Bag *
Required
Blue Jump Bag O2 PSI *
Blue Bag Glucose (min 2) *
Required
Blue Bag Aspirin 1 Bottle *
Required
Blue Bag Naloxone (min of 2) *
Required
Blue Bag Adult Epi-Pen *
Required
Red Jump Bag *
Required
Red Jump Bag O2 PSI
Red Bag Glucose (min of 2) *
Required
Red Bag Pediatric Epi-Pen *
Required
Fire Extinguisher *
Required
Bleeding Control Kit (Tagged) *
Required
Burn Kit (Tagged) *
Required
PPE and Sanitation Supplies *
Required
Interior Equipment *
Required
CPAP Mask *
Required
On-Board Aspirin 1 Bottle *
Required
On-Board Glucose (min 2) *
Required
OB Kit (min 2) *
Required
Bench Seat *
Required
Additional Comments or Missing Supplies
Crew Names *
Submit
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