Sunteți pe pagina 1din 4

P2H - AMBULANCE CHECKLIST

PERIODE : POLICY NUMBER :

WEEK 1
NO ITEM
1 2 3 4 5
1 Ambulance Exterior
- Front side
- Back side
- Cap
- Left side
- Right side

2 Ambulance front cabin


- Dashboard & lockers
* Fuel and temperature indicator
* Speedometer
* Tachometer (RPM)
* Odometer (km Jarak tempuh)
* Brake system indicator (system indikator rem)
* Oil indicator (indikator oli)
* Battery indicator (Battrey indikator)
- Windshield wiper (penghapus air kaca depan)
- Air Conditioner (AC)
- Steering wheel play (gerak setir)
- Gas
- Brake (rem kaki dan tangan)
- Coupling/Clutch
- Lighting system (non emergency) (Lampu sistem)
- Flash light & Siren (Sirine dan lampu tembak)
- Chairs + Seat Belt (kursi dan sabuk pengaman)
- Inside door wall Left & Right (dinding pintu dalam kanan dan kiri)
- Ceiling & floor (Plafon dan lantai)
3 Ambulance rear cabin
- Ceiling & floor (Plafon dan lantai)
- Windows and glass (Jendela dan layar kaca)
- Chairs + Seat Belt (kursi dan sabuk pengaman)
- Air Conditioner
- Fire Extinguisher (APAR)
- Lighting system (non emergency) (Lampu sistem)
- Equipments rack (APAR)
- Ambulance Bed Stretcher (1 set) - ( tempat tidur pasien)
- Pillow + Blanket +Bed sheet @ 1 pc

Pagr 1 of 4
P2H - AMBULANCE CHECKLIST

- Oxygen bottle (2 pcs) + Regulator (2 pcs)


- Oxygen flow meter + connector (1set)
- Infusion hanger (1 set)
- Medical emergency spotlight portable (2 set) (Lampu portable diatas bed)
- Slot for emergency spotlight portable (1 set) (Lampu di belakang pintu belakang)
4 Wheels & tyres (BAN)
- Front left & right ( Ban depan kanan dan kiri)
- Rear left & right ( Ban belakang kanan dan kiri)
- Spare tyre (ban serep)
5 Engine oil level / level oli mesin
6 Radiator coolant level/ Air pendingin radiator
7 Radiator and hoses (Radiator & selang )
8 Radiator, charge air cooler, and AC Condensor
(Radiator, keluaran pendingin udara dan
condensor AC)
9 Power steering
(fluid level between add & full mark)
10 Manual transmission fluid level
(Level oli transmisi)
11 Engine surpentine belt ( mesin perputaran belt seperti van belt dll)
12 Fluid leaks (Kebocoran oli)
13 Brake fluid level (Level minyak rem)
14 On Street (Km)
15 Fuel Condition
16 Type Of Fuel
17 First aid Box
18 Wastafel in back cabin
19 Miror / Spion
20 Other

C=complete, N= incomplete

Di check oleh Diketahui oleh

(.................) (.................)
Driver HSE

Pagr 2 of 4
No:
Rev: 00

EEK 1 REMARK
6 7

Pagr 3 of 4
incomplete

ketahui oleh

................)
HSE

Pagr 4 of 4