Free SP4161 - Wisconsin


File Size: 48.3 kB
Pages: 1
Date: June 17, 2004
File Format: PDF
State: Wisconsin
Category: Government
Author: DOTEKL
Word Count: 955 Words, 6,407 Characters
Page Size: 792 x 612 pts (letter)
URL

http://www.dot.wisconsin.gov/forms/docs/sp4161.pdf

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SP4161

AMBULANCE INSPECTION REPORT
6/2004
Ambulance Service Provider Name Vehicle Identification Number (VIN)
# 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. ITEM Headlights - High, Low Parking Lights - Front, Rear Turn Signals - Front, Rear Fog Lights Grill Lights License Plate Tires - Front, Rear Warning Lights Front, Side, Rear Light Bar - Front, Rear Clearance Lights - Front, Rear Side Marker Lights Intersection Lights Lettering - Side, Rear 4 Inch Striping Flood Lights - Side, Rear Doors - Side, Rear Door(s) - Compartments Door Seals Steps - Rear, Side Step Lamp(s) Tail Lights Stop Lights Backup Lights Backup Alarm License Plate(s) and Light Windshield Windows Windshield Wipers/Washers Spotlight(s) No Smoking Sign - Cab, Rear Heater, Defroster - Cab Air Conditioning - Cab Horn Siren Mirrors Dome Lamp - Cab Instrument Panel Lamps Master Switch Panel Lamps Open Door Indicators Speedometer Brakes Emergency Brakes Emergency Brake Dash Lamp Communications Equipment PA System Exhaust System Battery System Fuel System Structurally Safe Width Height Length Interior Lighting Heater / Air Conditioning OK OK
NOT

Wisconsin Department of Transportation
Address Where Domiciled/Stationed Year, Make
# 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72.

Biennial Inspection Spot -Check Insp.

Re-Inspection Level Upgrade

In-Service Unit Reserve Unit County

EMT-B EMT-BIV EMT-I

Specialized Other Inspection Date

EMT-P

Plate Number, Year Expires
ITEM

Unit Number
OK OK
NOT

Odometer Reading
ITEM

Conversion Manufacturer
OK OK
NOT

Type 1 2
ITEM

Provider Number 3 Other:
OK NOT OK

# 103. 104. 105 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138.

# 1. 2. 3. 4. 5.

Auto Setting

Semi-Auto

Manual J J J J J J No

Flooring - Wall Seal Control Panel Lamps Exhaust Fan Main Oxy. System / Supply Main Suction System

Medical and Other Items

Patient Compartment

Proof of Current Registration Remote Two-Way Communication Commercial Wheeled Cot Straps for Cot Shoulder Straps for Cot Chair Stretcher Battery Powered Portable Suction Suction Tubing- 3 ft. Long, 6 ft. Long Suction Tips Portable O 2 Unit- 13 Cubic Ft. or> (1) Full Spare Portable O 2 Cylinder (1) Set of Oral Airways- Sized 0-6 (6) Or More Nasopharyngeal Airways Sized 12 fr. - 34 fr. 73. Transparent Nonrebreathing Reservoir O2 Masks with Tubing (2) Adult, (2) Child 74. (2) Infant Sized O 2 Mask with Adequate Length Tubing 75. (2) Adult Nasal Cannula 76. (1) Bag-Valve-Mask Unit for each Adult, Child, Infant 77. Water Soluble Lubricant 78. (50) Sterile Gauze Pads, 4x4 or > 79 (4) Sterile Occlusive Dressings at Least 3x9 80. (2) Rolls of Medical Tape, 2 or > 81. (2) Clean Burn Sheets 82. (8) Triangular Bandages 83. (6) 10X30 Universal or Trauma Dressings 84. (12) Soft-Rolled, Self-AdheringBandages,3 Wideor > 85. (1) Bandage Shears, 7 or > 86. (1) Large Adult BP Cuff 87. (1) Regular Adult BP Cuff 88. (1) Child BP Cuff 89. (1) Stethoscope 90. Adult Size Traction Splint 91. Pediatric Size Traction Splint or Documented Methodology for the Stabilization of a Pediatric Femur Fracture, Signed by the Med. Dir. 92. (2) Long Spine Boards 93. Appropriate Straps for Long Boards 94. (1) Short Spine Board 95. (1) Child Sized Spine Board 96. (2) Splinting Devices at Least 3 Long 97. (2) Splinting Devices at Least 15 Long but < Item 96 98. (2) Liters of Sodium Chloride for Irrigation 99. Obstetrical Kit 100. Laryngoscope - Adult, Ped. 101. Magil Forceps - Adult, Ped. 102. (1) Orthopedic Stretcher

(2) Rigid C-Collars - Adult Sizes (2) Rigid C-Collars - Peds. Sizes (2) Rigid C-Collars - Infant Sizes (3) Or More Eye Protection Units (3) Or More Surgical Masks (3) Or More Pairs of Non-Sterile Gloves (3) Or More Jumpsuits or Gowns that are Disposable and Impervious to Body Fluids (3) Or More Disposable Shoe Covers Antimicrobial Hand Wash Commercial Sharps Container Bio-Hazard Bags Latex Free Equipment and Supplies Directed by a Protocol. Signed by the Services Med. Dir. (2) Cervical Head Immobilizer Sheets / Blanket / Pillow Liquid Oral Glucose Defibrillator - Per DHFS Plan (2) Adult, Pediatric Defibrillator Pads (2) Advanced Airways Epinephrine - Per DHFS Plan Current Drug List - Per Med. Dir. (2) Plug-in O 2 Flowmeter Fire Extinguisher - Rear, Front No-Smoking Signs - Rear, Front (2) Portable, Battery Operated Lights (3) Reflectors or Red Lights Sticks (1) 12-inch Adjustable Wrench (1) Screwdriver - Slot (1) #2 Phillips Screwdriver (1) Hacksaw and 12 inch Blades (1) 10 Inch Looking Grip Pliers (1) 16 oz. Hammer (1) 24 Inch Wreaking Bar Impact Resistant Eye Protection (1) Pair of Leather Gloves (1) Roll of 2 Inch Duct Tape (1) Spring Loaded Center Punch

Oxygen Regulator Oxygen Flow Meters Suction - 300mm w/4sec. Blood Pressure Gauges Defibrillator

Items Tested

Result

J J J J J J Wave Form

Yes

ITEM #

REMARKS / EXPLANATION

Interior in sanitary condition Vehicle certified to operate Vehicle ordered out-of-service

No

Yes

Citation to be issued for violation(s) Warning Sect.# Violation

DO NOT OPERATE UNTIL REPAIRED AND REINSPECTED

Days to return report
VEHICLE DEFECTS HAVE BEEN CORRECTED

Ambulances Staffed with EMT-BIV and EMT-I Shall Carry in Addition to the Above
Sterile Intravenous Infusion Agent IV Stating Equipment Adult and Pediatric Sized IV Cath. Subcutaneous Injection Equipment Prepackaged Medications, Drugs and Solutions - Per DHFS Plan

139. 140. 141. 142. 143.

X

(Authorized Member of Service)

Ambulances Staffed with EMT-I and EMT-P Shall Carry in Addition to the Above
144. (1) Pediatric Stethoscope 145. (2) Or More Intraosseous Needles 146. Endotracheal Intubation Equipment Infant - Adult 147. Medications and Drugs per M.C. 148. Electrocardiogram Monitor w/Tape 149. Pediatric Paddles or (2) Pads 150. Pediatric and Adult Sized Endotracheal Tube Stylettes 151. Length / Weight-based Drug Dose Chart or Tape

MAIL TO: Wisconsin Dept. of Transportation Division of State Patrol P.O. Box 7912 Madison, WI 53707-7912

X

(Driver/EMT) (DSP Representative)

X

DISTRIBUTION 3 copies: 1) Office; 2) Provider; 3) Provider must sign and return when defects are corrected.