Ambulance Daily Inspection Form Checklist

=Yes/Good/
S/No. DESCRIPTION OF CHECKS REMARKS
=No/Bad
Ambulance Physical Condition
General Vehicle Condition
Is the exterior of the vehicle clean and
free of damage?
If damage is noted please take a photo
of the damaged area? Upload Media
Is the interior cab of the ambulance clean
and free off damage?
If there is damage noted in the cab of the
ambulance please take a picture.
Is the patient compartment clean and free
of damage?
If damage is noted in the patient
compartment please take a picture
Protocol book on unit?
Fuel and general engine fluids check
Fuel level at checkout? (Indicate the
closest amount)
1/8
1/4
1/2
3/4
Full
Are engine oil levels acceptable?
Are windshield wiper fluid levels
acceptable?
Is there any indication of leaking fluids?
Emergency Alert Systems and General
Lights
Headlights functional?
Emergency lights functional?
Sirens functional?
Backup alarm functional

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S/No. DESCRIPTION OF CHECKS REMARKS

Brake lights functional

Tail lights functional?
Turn lights functional?
Any additional detail as necessary for any
negative findings other than above?
Patient care equipment
Stretcher present and in good condition?
Stretcher patient restraints including
shoulder straps present?
Airway bag is present, stocked correctly
with a charged oxygen cylinder?
Portable oxygen pressure level? (Indicate
to the nearest hundred)
min: 0
max: 2000
step: 100
Patient Compartment
Linens stored and clean?
Regular Trash Can Present?
Safety Equipment
2 Hard hats with goggles?
2 Pair gloves?
2 Safety Vests
1 Flashlight
3 Road Reflectors
1 First Aid kit
Hand Sanitizer
1 Fire Extinguisher Cab,
1 Fire Extinguisher patient compartment?
Adult Nebulizer Count

min: 0
max: 10

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