Rig Check

Rig Check

Complete an inspection daily to ensure response readiness.
Date*

MonthDayYear
Vehicle type*

Ambulance
Staffing level*

BLSALS
Station/assignment*

EvansGobbiSouthWillits
Vehicle number*
Radio designator*
Employee 1*

First NameLast Name
Employee 2

First NameLast Name
Employee 3/Rider

First NameLast Name

Vehicle
Odometer*
Enter current odometer reading in miles.
Fuel cards*

Commercial Fuel Network (CFN)Pacific Pride (PAC)Both CFN and PACNone

Vehicle exterior - Use the list below to guide your inspection. Only check items that need to be reported. Items marked with a star are required by CHP.

	REPORT ITEM
Engine oil
Coolant
Brake fluid
Power steering fluid
Transmission fluid (Ford vehicles)
Belts and hoses
Washer fluid
Body damage
Tire tread and inflation ★
Headlights (low and high beam) ★
Parking and clearance lights ★
Taillights ★
Brake lights ★
Back-up lights and alarm ★
Turn signals ★
Scene and load lights
License plate light ★
Steady-burning red emergency light (to front) ★
Other primary and secondary emergency lights ★
Lenses and reflectors ★

Vehicle interior - Use the list below to guide your inspection. Only check items that need to be reported. Items marked with a star are required by CHP.

	REPORT ITEM
Start and warm engine
Fuel level (minimum 3/4 tank)
Gauges, indicators and dash lights ★
Windshield, wipers and other windows ★
Mirrors ★
Defroster, heater and AC ★
Vehicle horn ★
Siren (test only as appropriate for time and location) ★
Dome and reading lights ★
Flashlight ★
Spotlight (if equipped)
Seat belts ★
Safety vests (2)
Gloves (all sizes)
Mobile radios (VHF and UHF)
Portable radios (2)
Clipboard with backup paper forms
Map books (paper or electronic) ★
Vehicle log book (registration, insurance, CHP certificate) ★
iPad and charging cable
Bluetooth keyboard for iPad (built into case or separate)
FasTrak tag
Bay door opener (Evans)
Water (for low coolant or overheat)
Road flares
Spare tire, jack and tools ★
Fire extinguisher (charged) ★

Fire extinguisher last inspection date*
Provide MM/YYYY of last inspection, or make note if date is not indicated, unreadable or tag is missing
All interior and exterior vehicle components have been inspected and are in satisfactory condition?*

YesNo (see comments)
Vehicle comments

Patient Compartment

Patient compartment BLS equipment and supplies - Use the list below to guide your inspection. Only check items that need to be reported. Items marked with a star are required by CHP.

	REPORT ITEM
Gurney (charged battery, safety belts, pillow, blanket) ★
BP cuff and stethoscope on bench ★
Portable suction with tubing and tip
On-board suction with tubing and tip
Inverter
Dome lights (low and high beam)
Exhaust vent
Backboards (2) ★
Scoop or break-away flat
KED
Stair chair
Pediatric board
Pediatric car seat or Pedi-Mate
Traction splint ★
Rigid splints (foam or cardboard x4) ★
BVMs (adult, pediatric, infant) ★
Spare suction canister, tubing and tip
Nasal cannulas (adult x6, pediatric, infant) ★
Non-rebreather masks (adult x6, pediatric, infant) ★
CPAP
Bulb syringe
O2 tubing
OPA set ★
NPA set with lubricating jelly
Sterile saline (2 liters) ★
Sterile water (2 liters)
Soft restraints (4 pair) ★
Burn sheets (2)
Multi-trauma dressings (2) ★
4x4s (sterile x4, bulk x6) ★
Roller gauze (2", 3", 4", 6" x3 ea) ★
5x9 sterile dressings (6) ★
8x10 sterile dressings (6) ★
Band-Aids
Tape (cloth x2, Transpore x2) ★
Trauma shears ★
Hot packs (6)
Cold packs (6)
OB kit ★
BP cuffs (thigh, adult, pediatric, infant)
Stethoscope
Emesis basins or hoops (4) ★
Chucks (6)
Bedpan ★
Urinal ★
Isolation kits (2)
N95 masks (5)
Safety glasses (2)
Garbage bags
Biohazard bags
Garbage can (emptied)
Spare portable O2 tanks (minimum 1000 PSI x2)
Paper towels
Cleaning solution or sanitizing wipes
Sheets (4) ★
Pillow cases (4) ★
Blankets (2) ★
Spare pillow ★
Towels (2) ★
Highway blankets (2)
MCI kit
CVEMSA treatment guidelines (hardcopy)

Main O2 tank pressure*
H or M cylinder minimum 500 psi

Patient compartment ALS equipment and supplies - Use the list below to guide your inspection. Only check items that need to be reported.

	REPORT ITEM
IV catheters (14G, 16G, 18G, 20G, 22G, 24G x6 ea)
IV start packs (6)
Alcohol wipes
Saline locks (5)
Saline flushes (8)
Large sharps container
Blunts or Twinpaks (5)
Filter needles (2)
Fill needles (4)
IM needles (4)
Syringes (1cc, 3cc, 5cc, 10cc x4 ea, 20cc x2)
0.9% NS bags (500ml x3, 1000ml x6)
Macrodrip tubing sets (6)
Microdrip tubing sets (2)
Blood Y tubing set
Dial-a-flows (2)
Arm boards (large, small)
i-Gel airways (1, 1.5, 2, 2.5, 3, 4, 5)
Stylets (adult, pediatric)
Endo-ject
CO2 detectors (adult, pediatric)
Suction catheters (8Fr, 10Fr, 14Fr, 18Fr)
Aerosol masks (adult, pediatric)
Spare ECG leads
Spare ECG recorder paper
Multi-function pads (adult, pediatric)
AID magnet
EZ IO
PVAD kit
Thoracentesis kit
Magnesium sulfate
Pitocin
ET tubes (5.0-9.0)

All patient compartment equipment and supplies have been inspected and are in satisfactory condition?*

YesNo (see comments)
Patient compartment comments

Airway Bag

Airway bag BLS equipment and supplies - Use the list below to guide your inspection. Only check items that need to be reported.

	REPORT ITEM
Nasal cannula
Non-rebreather mask
CPAP
OPA set
NPA set with lubricating jelly
BP cuff
Stethoscope
BVMs (adult, pediatric)
Glucometer (calibrated)
BG test strips
Lancets
Alcohol wipes
Band-Aids
Sharps container

Portable O2 tank pressure*
D or E cylinder minimum 1000 psi
BLS drug box sealed?*

YesNo
BLS drug box seal number*

All airway bag equipment and supplies have been inspected and are in satisfactory condition?*

YesNo (see comments)
Airway bag comments

	REPORT ITEM
Aspirin chewables
Epinephrine auto-injectors (0.3mg x2)
Oral glucose
Narcan pre-loads (2mg x2)

The AED has been inspected and is in satisfactory condition?*

YesNo (see comments)
AED comments

	REPORT ITEM
Status light or indicator shows good
Defib pads

Monitor
Complete monitor self-test and submit a picture of the strip. *

Browse Files

Cancelof

The monitor and related equipment and supplies have been inspected and are in satisfactory condition?*

YesNo (see comments)
Monitor comments

	REPORT ITEM
Charged batteries (one in monitor, one spare)
Adult electrodes (minimum 12)
Multi-function pads (adult, pediatric)
12-lead cables (first-out ambulances)
Razor
AC power cord
Extra recorder paper
SpO2 cable
SpO2 probes (adult, pediatric)
ETCO2 zero reference module
ETCO2 devices (ETT, nasal)

ALS Med Bag

ALS med bag - Use the list below to guide your inspection. Only check items that need to be reported.

	REPORT ITEM
Adenosine (6mg x3)
Amiodarone (150mg x3)
Aspirin chewables
Atropine pre-load (1mg)
Atropine multi-dose (8mg)
Benadryl ampoules (50mg x2)
Ca chloride 10% pre-load (1mg)
D10 bag (250mg)
D50 pre-load (25g)
Epinephrine pre-loads (1:10,000 x3)
Epinephrine ampoules with filter needle (1:1000 x4)
Glucagon
Oral glucose
Ketorolac (30mg x2)
Narcan pre-loads (2mg x2)
Nitroglycerin tablets
Sodium bicarb 8.4% pre-load
TXA (1g)
Zofran IV (4mg x3)
Zofran SL (4mg x3)
IV catheters (16G, 18G, 20G, 22G x2 ea)
Start packs (2)
Alcohol wipes
4x4s
Transpore tape
Saline locks (2)
Saline flushes (2)
Blunts or Twinpaks (4)
Filter needle
Fill needles (4)
IM needles (4)
0.9% NS bags (50ml, 100ml, 1000ml)
Macrodrip tubing (2)

All ALS med bag equipment, medications and supplies have been inspected and are in satisfactory condition?*

YesNo (see comments)
ALS med bag comments

ALS Drug Box
ALS drug box sealed?*

YesNo
ALS drug box seal number*

All ALS drug box medications have been inspected and are in satisfactory condition?*

YesNo (see comments)
ALS drug box comments

	REPORT ITEM
Albuterol pillows (2)
Amiodarone (150mg x3)
Apirin chewables
Atrovent pillow
Benadryl ampoule (50mg)
Ca chloride 10% pre-load (1mg)
D50 pre-load (25g)
D10 bag (250mg)
Epinephrine pre-loads (1:10,000 x3)
Epinephrine ampoules (1:1000 x2)
Glucagon
Oral glucose
Ketorolac (30mg)
Narcan pre-loads (2mg x4)
Nitroglycerin tablets
Sodium bicarb 8.4% pre-load
TXA (1g)
Zofran IV (4mg x2)
Zofran SL (4mg x2)
0.9% NS bags (50ml, 100ml)

Controlled Substances
Paramedic in possession of narc box keys?*

YesNo
Controlled substance sign-out form completed?*

YesNo
Narc box sealed?*

YesNo
Narc box seal number*
Fentanyl*
Enter quantity available in micrograms. If less than 300mcg, notify supervisor immediately unless substituted with morphine.
Ketamine*
Enter quantity available in milligrams. If less than 50mg, notify supervisor immediately.
Versed*
Enter quantity available in milligrams. If less than 15mg, notify supervisor immediately.
Morphine*
Enter quantity available in milligrams. When stocked as a substitute for fentanyl and less than 30mg, notify supervisor immediately.

Pediatric Bag
Pediatric bag sealed?*

YesNo
Pediatric bag seal number*

	REPORT ITEM
Nasal cannulas (pediatric, infant)
Non-rebreather masks (pediatric, infant)
Infant BVM
Bulb syringe
OPA set
NPA set with lubricating jelly
BP cuffs (pediatric, infant)
Stethoscope
4x4s
Roller gauze
Band-Aids
Broselow tape
Handtevy tape

Pediatric bag ALS equipment and supplies - Use the list below to guide your inspection. Only check items that need to be reported.

	REPORT ITEM
Laryngoscope handle
Laryngoscope blades (Miller 0 & 1, Mac 1 & 2)
Pediatric Magill forceps
i-Gel airways (1, 1.5, 2)
Pediatric stylet
Pediatric CO2 detector
Pediatric tube holder
Meconium aspirator
Suction catheter set
Spare AA batteries (2)
Spare laryngoscope bulbs
Pediatric aerosol mask
IV catheters (20G, 22G, 24G)
Alcohol wipes
Transpore tape
Saline locks (2)
Saline flushes with blunts or Twinpaks (2)
0.9% NS bag (500cc)
Microdrip tubing
Dial-a-flow
Stopcock
Sharps container
Pediatric electrodes
Epinephrine pre-load (1:10,000)
Narcan pre-load
Sodium bicarb 4.2% pre-load
Pediatric IO kit with lidocaine pre-load
CVEMSA medication cards

All pediatric bag equipment and supplies have been inspected and are in satisfactory condition?*

YesNo (see comments)
Pediatric bag comments

Trauma Bag
Trauma bag sealed?

YesNo
Trauma bag seal number

Trauma bag BLS equipment and supplies - Use the list below to guide your inspection. Only check items that need to be reported.

	REPORT ITEM
Burn sheet
Trauma dressing
5x9 sterile dressing
4x4s
Roller gauze
Tape (cloth, Transpore)
OPA set
NPA set with lubricating jelly
Bulb syringe
Cold packs (2)
Hot packs (2)
Sterile saline (1 liter)
Gloves
Flashlight
Safety glasses or goggles
Trauma shears

Trauma bag ALS equipment and supplies - Use the list below to guide your inspection. Only check items that need to be reported.

	REPORT ITEM
IV catheters (14G, 16G, 18G, 20G x2 ea)
Alcohol wipes
Saline locks (2)
Saline flushes with blunts or Twinpaks (2)
0.9% NS bag (1000cc)
Macrodrip tubing
20cc syringe
Sharps container

All trauma bag equipment and supplies have been inspected and are in satisfactory condition?*

YesNo (see comments)
Trauma bag comments

Spinal Care Bag

Spinal care bag - Use the list below to guide your inspection. Only check items that need to be reported. Items marked with a star are required by CHP.

	REPORT ITEM
C-collars (fixed x1 ea or adj adult x3, adj pediatric x2) ★
Spider straps (2) ★
Head blocks (2 pair) ★
Cloth tape
Trauma shears

All spinal care bag equipment and supplies have been inspected and are in satisfactory condition?*

YesNo (see comments)
Spinal care bag comments

Sign and Submit
Employee 1 signature*

By signing, you certify that you have completed your inspection and the information provided is true and correct. Clear
Employee 2 signature*

By signing, you certify that you have completed your inspection and the information provided is true and correct. Clear
Should be Empty:

	REPORT ITEM
Laryngoscope handle
Laryngoscope blades (Miller 2 & 3, Mac 3 & 4)
Adult Magill forceps
i-Gel airways (2.5, 3, 4, 5)
Adult stylet
Bougie (ETTI)
Lubricating jelly
10cc syringe
Adult CO2 detector
Syringe-style tube check
Endo-ject
Adult tube holder
Suction catheters (8Fr, 10Fr, 14Fr, 18Fr)
Spare C batteries (2)
Spare laryngoscope bulbs
Hand-held nebulizers (2)
Aerosol masks (adult, pedi)
Albuterol pillows (4)
Atrovent pillows (2)
Thoracentesis kit