This form is provided courtesy of the Iowa Bureau of EMS. It is NOT mandatory that you use this form.
EQUIPMENT CHECKLIST
SERVICE: ______DATE: _____/______/19____
Completed by: ______
DEFIBRILLATOR: (circle one) Comments and/or deficiencies:
1. Battery charged: yes no NA
2. Self test OK yes no NA
3. Clean tape/rewound yes no NA
SUCTION UNIT:
1. Unit tested & working yes no NA
2. Battery charged yes no NA
3. Tubing clean/ready for use yes no NA
OXYGEN TANK(s):
1. Valve open-level checked:
(level in PSI) 1.______2. ______3. ______4. ______
2. Tank(s) below 500 PSI
filled of changed: yes no NA
3. Tanks ready for use yes no NA
JUMP KIT:
1. Checked of required
supplies & equipment: yes no NA
2. Supplies restocked yes no NA
3. Other storage areas yes no NA
OTHER:
1. ______yes no NA
2. ______yes no NA
3. ______yes no NA
4. ______yes no NA
5. ______yes no NA
6. ______yes no NA
7. ______yes no NA
8. ______yes no NA
NO: REQUIRES COMMENT - NA: NOT APPLICABLE
EQUIPMENT CHECKLIST
SERVICE: ______DATE: _____/______/19____
Vehicle(s): #____ #____ Completed by: ______
DEFIBRILLATOR: (circle one) Comments (No requires comment):
# # 1. Battery charged: YES NO NA
# # 2. Defibrillator pads (& monitoring) YES NO NA
# # 3. Clean, tape/rewound, cables (& reserve) YES NO NA
SUCTION UNIT:
# # 1. Unit tested & working YES NO NA
# # 2. Tubing clean/ready for use YES NO NA
OXYGEN TANK(s):
# # 1. Valve open-level checked: (level in PSI) YES NO NA
tank(s) #1______#2 ______#3 ______#4 ______
# # 2. Tank(s) below 500 PSI filled or changed: YES NO NA
JUMP KIT(s):
# # 1. Checked of required supplies & equipment: YES NO NA
# # 2. Supplies restocked YES NO NA
# # 3. Other storage areas YES NO NA
OTHER: (List other equipment or items to be checked
# # 1. ______YES NO NA
# # 2. ______YES NO NA
# # 3. ______YES NO NA
# # 4. ______YES NO NA
# # 5. ______YES NO NA
# # 6. ______YES NO NA
# # 7. ______YES NO NA
# # 8. ______YES NO NA
# # 9. ______YES NO NA
# # 10. ______YES NO NA
# # 11. ______YES NO NA
# # 12. ______YES NO NA
# # 13. ______YES NO NA
# # 14. ______YES NO NA
# # 15. ______YES NO NA
# # 16. ______YES NO NA
# # 17. ______YES NO NA
VEHICLE / EQUIPMENT CHECKLIST
SERVICE: ______DATE: _____/______/19____
Vehicle(s): #_____ #_____ Completed by: ______
DEFIBRILLATOR: (circle one) Comments (No requires comment):
# # 1. Battery charged: YES NO NA
# # 2. Defibrillator pads (& monitoring) YES NO NA
# # 3. Clean, tape/rewound, cables (& reserve) YES NO NA
SUCTION UNIT:
# # 1. Unit tested & working YES NO NA
# # 2. Tubing clean/ready for use YES NO NA
OXYGEN TANK(s):
# # 1. Valve open-level checked: (level in PSI) YES NO NA
tank(s) #1______#2 ______#3 ______#4 ______
# # 2. Tank(s) below 500 PSI filled or changed: YES NO NA
JUMP KIT(s):
# # 1. Checked of required supplies & equipment: YES NO NA
# # 2. Supplies restocked YES NO NA
# # 3. Other storage areas YES NO NA
OTHER: (List other equipment or items to be checked
# # 1. ______YES NO NA
# # 2. ______YES NO NA
# # 3. ______YES NO NA
# # 4. ______YES NO NA
# # 5. ______YES NO NA
# # 6. ______YES NO NA
# # 7. ______YES NO NA
VEHICLE(s)
# # 1. Fluid levels (gas, oil, window wash) YES NO NA
# # 2. Lights (head/ tail lights, emergency) YES NO NA
# # 3. Tires, belts, hoses, windshield wipers YES NO NA
# # 4. Cleanliness (inside & outside) YES NO NA
# # Date last serviced ____/____/_____ mileage: ______
# # Date last serviced ____/____/_____ mileage: ______
02-20-2002 vehicle and equipment checklists.doc