NEONATAL TRANSPORT
VEHICLE INSPECTION SUPPLEMENT
Date:
Service: Permit No.:
Pass Fail
Inspector’sSignature:
EQUIPMENT
A U(A = Acceptable U = Unacceptable)
Transport Incubator
Thermometer
Blanket (insulating blanket or chemically activated warm pack approved for neonate use)
Above equipment maintained in neutral thermal environment.
PH-3941 (Rev 7-2017)Page 1 of 2RDA - 10137
OXYGEN DELIVERY & MONITORING
A U(A = Acceptable U = Unacceptable)
Oxygen Tanks
Air Tanks
Pressure Gauges
Flow-Meters
Oxygen Analyzer
Oxygen Blender
Oxygen Tubing and Adapters
Oxygen Hood orNasal Cannula
Neonatal Oxygen Mask
Neonatal Resuscitation BVM
(with Manometer)
Continuous Positive Airway
Pressure Apparatus
Mechanical Ventilator
Non-Invasive Oxygen Monitor
(i.e. Pulse Ox)
AIRWAY / GASTRIC DECOMPRESSION
A U(A = Acceptable U = Unacceptable)
Bulb Syringe
Regulated Suction w/Gauge
Suction Catheters (#6, 8, 10 Fr)
Feeding Tube (# 8 Fr.) w/20 ml Syringe
Replogle Tube (#8 Fr.)
MONITORING (VITAL SIGNS)
A U(A = Acceptable U = Unacceptable)
Continuous Heart-Rate Monitor
Neonatal Stethoscope
Body Temperature Monitor
Non-Invasive & Invasive BP Monitor
Glucometer or Equivalent
PUMPS
A U(A = Acceptable U = Unacceptable)
IV Pump
(portable, battery powered, failsafe & calibrated)
ENDOTRACHEAL INTUBATION
A U(A = Acceptable U = Unacceptable)
Laryngoscope Handle with Blades (00, 0, 1)
Spare Laryngoscope Bulbs
Spare Batteries
ET Tubes (# 2.5, 3.0, 3.5, 4.0 mm I.D.)
Disposable Stylette (# 6 Fr.)
Adhesive Tape
Scissors
INTRAVENOUS INFUSIONS
A U (A = Acceptable U = Unacceptable)
Intravenous Needles/Catheters
(22, 23, 24, 25, 26 gauge)
Syringes (1, 3, 6, 12, 20, 35 ml)
Intravenous Arm-Board
Intravenous Tubing
Infusion Device
Tape
Alcohol Preps
Betadine Preps
3-Way Stopcock
Umbilical Catheterization Equipment
MEDICATIONS / ADMIXTURES
Therapeutic Equivalents are Acceptable
A U(A = Acceptable U = Unacceptable)
Adenosine (antiarrythmic)
Ampicillin (antibiotic)
Atropine (antispasmotic)
Calcium Gluconate
Chloral Hydrate (sedative)
Dextrose Solution (D5W)
Dextrose Solution (D10W)
Digoxin (antiarrythmic)
Dobutamine (adrenergic)
Dopamine (Sympathomimetic)
Epinephrine (1:10,000)
Fentanyl (narcotic)
Furosemide (diuretic)
Gentamicin (antibiotic)
Heparin (anticoagulant)
Morphine Sulphate (narcotic)
Naloxone Hydrochloride
Normal Saline
Phenobarbitol (anticonvulsant)
Protaglandin E1 (require refrigeration)
Sodium Bicarbonate (4.2%)
Sterile Water
Surfactant (requires refrigeration)
EQUIPMENT FOR DIAGNOSIS & MANAGEMENT OF AIR-LEAK SYNDROME
A U (A = Acceptable U = Unacceptable)
Transilluminator
Chest Tubes (8, 10, 12)
Chest Tube Kit
25g Angiocath or Butterfly
Heimlich Valve
3-Way Stopcock
Luer Lock and Slip Tip Syringe (35/60ml)
EQUIPMENT FOR HANDWASHING
AND PERSONAL PROTECTION
A U(A = Acceptable U = Unacceptable)
Antiseptic Solution or Towelettes
Gloves
Full-face Protection or Goggles andMask
Fluid-Retardant and Fluid-Resistant Gowns
Infectious Waste Disposal Bags
Soiled Linen Disposal Bags
Sharps Box
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COMMENTS
LATEX FREE EQUIPMENT AND SUPPLIES SHOULD BE AVAILABLE
PH-3941 (Rev 7-2017)Page 1 of 2RDA - 10137