AMBULANCE INSPECTION REPORT Wisconsin Department of ...

AMBULANCE INSPECTION REPORT

Wisconsin Department of Transportation

SP4161

3/2021

Ambulance Services Provider Name

Vehicle Identification Number (VIN)

Address Where Domiciled/Stationed

Year, Make

Plate Number, Year Expires

Unit Number

Odometer Reading

County

Provider Number

Conversion Manufacturer

Type

I

#

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 (Optional)

Grill Lights

License Plate

Tires - Front, Rear

Warning Lights Light Bar - Front, Rear

Clearance Lights - Front, Rear

Side Marker Lights

Lettering - Side, Rear

4 Inch Striping

Flood Lights - Side, Rear

Doors - Side, Rear

Door(s) - Compartments

Door Seals

Steps - Rear, Side

Tail Lights

Stop Lights

Backup Lights

Backup Alarm

License Plate Light

Windshield

Windows

Windshield Wipers/Washers

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

Parking Brake

Parking Brake Dash Lamp

Communications Equipment

PA System

Exhaust System

Battery System

Fuel System

Structurally Safe

Steering System

Belts (Drive)

Suspension

GVWR Exceeded

GAWR Axle/s Exceeded

Patient Compartment

Width

Height

Length

STATUTE

309.15(1) & 347.09(1)(a)

309.15(1) & 347.09

309.15(1) & 347.15(2)(3)

347.26(3)(a,b)

309.15(2)(a)(5)

341.15

309.12(1-5)

309.15(2) & 347.25(1)

309.15(2)

309.15(1) & 347.16(1)(a,b)

309.15(1) & 347.16(1)(c)

309.19(2)(a)

309.19(b)

309.15(3)

309.10

309.10

309.10

309.11

309.15(1) & 347.13(1)

309.15(1) & 347.14(1)

309.15(1) & 347.26(4)(a)

.

309.15(1) & 347.13(3)

347.43

347.43

347.42

309.205(1)(c)

309.14

309.14

347.38(1)

309.17(1)(1m)

347.40(1)

309.16(1)

309.16(1)

309.16(1)

309.16(1)

347.41

347.35(1)

347.35(1a)

309.16(1)

309.18(1)

309.17(1)

309.03(5)(b)

309.13

309.03(5)(d)

309.03(5)(f)

309.03(5)(p)

309.03(5)(q)

309.03(5)(r)

309.03(5)(s)

309.03(5)(t)

309.09(1)(b)

309.09(1)(c)

309.09(1)(a)

OK

NOT

OK

#

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

82.

83.

84.

85.

86.

87.

88.

89.

90.

91.

92.

93.

94.

95.

96.

97.

98.

99.

ITEM

Interior Lighting

Heater/Air Conditioning

Flooring- Wall Seals

Control Panel Lamps

Exhaust Fan

Main Oxygen System/Supply

Main Suction System

Medical and Other Items

Current Registration Carried

Current Insurance Carried

Drug List

Maintenance Records

Crash Register

Emerg. Response Guidebook

Port. Carbon Monoxide Det.

Remote Two Way Communication

Commercial Wheeled Cot

Straps for Cot

Shoulder Straps for Cot

Chair Stretcher

Battery Powered Portable Suction

Suction Tubing 3 & 6 ft long

Suction Tips

Portable O2 Unit-13 cubic ft or more

Full Spare Portable O2 Cylinder

Oral Airways 0-5

Nasopharyngeals 16F-34F

Transparent Nonrebreathing & Valveless

O2 Masks w/Tubing Adult & Child

Adult, Child & Infant Nasal Cannulas

Adult, Child & Infant Nebulizers

Tracheostomy tube, if an approved skill

Bag Valve Mask Unit for Each- Adult, Child, Infant

2 Approved Non-visualized advanced Airways

Laryngoscope Adult & Peds Blades

Adult & Peds Forceps

Water Soluble Lubricant

Pulse Oximeter w/Adult & Peds Probes

Blood Glucose Monitoring Equip

Bandaging

1 .Burn Sheets 2 minimum

2. Triangular 2 minimum

3. Sterile Multi-trauma dressings, Large & Small

4. Abdominal dressings 10X12¡± or larger

5. 4X4¡± gauze sponges or suitable size

6. Gauze rolls, various sizes

7. Occlusive dressing or equivalent, sterile 3X8¡± or larger

8. Adhesive Hypoallergenic Tape various sizes

Arterial Tourniquet

Heavy Bandage or Paramedic Scissors

Sphygmomanometer Adult Reg, Lg & Ped

Stethoscope Adult & Ped

C-Colars Adult & Ped 2 yoa & older

Head Immobilization devices Adult & Ped

Lower Extremity Immobilization, femur tract. Adult & Ped

STATUTE

309.16(2)

309.14

309.09(2)

309.16(2)

309.14

309.23(1)

309.22(1)

309.08(1)

309.08(1)

309.08(2)

309.08(3)

309.08(4)

309.205(f)

309.205(i)

309.18(2)

309.21(1)

309.21(2)

309.21(2)

309.21(1)

309.22(2)

309.22

309.22

309.23(2)

309.23(2)

309.24(1)(c)

309.24(1)(cm)

309.24(1)(am)

309.24(1)(am)

309.24(1)(am)

309.24(1)(am)

309.24(1)(b)

309.24(1)(bm)

309.24(1)(br)

309.24(1)(cr)

309.24(1)(d)

309.24(1)(e)

309.24(1)(em)

309.24(1)(f)

309.24(1)(fm)

309.24(1)(fr)

309.24(1)(m)

309.24(1)(h)

309.24(1)(i)

309.24(1)(im)

309.24(1)(j)

OK

NOT

OK

#

I-AD

ITEM

100. Upper & Lower Extremity Immobilization devices

101. Immobilization Devices Impervious Long &

Short Extrication Boards and 3 straps, capabilities

to add padding for children. Radiolucent preferred

102. Orthopedic, scoop break apart stretcher

103. Obstetrical Kit

1. Sterile Gloves

2. Scissors or other cutting utensil

3. Umbilical cord clamps

4. Sterile Dressings

5. Towels

6. Bulb suction or bulb syringe

7. Thermal absorbent blanket and head cover, aluminum foil roll,

or appropriate heat-reflective material, enough to cover a newborn

104. Length/weight-based tape/ref. material

105. Thermometer with Low temp capability

106. Commercial cold & hot packs

107. Sterile Saline bottles or bags

108. Blanket, min of 4 sheets, linen or paper and pillow

109. Towels

110. Disposable emesis bags or basins

111. Disposable bed pan

112. Disposable urinal

113. Infection Control Equip

1. 3 or more-Eye Protection Units

2. 3 or more-Surgical Masks

3. 3 or more-Nonsterile gloves

4. 3 or more-Jump suits or gowns that are impervious to body fluids

5. 3 or more-Disposable Shoe Covers

6. Waterless hand cleanser, commercial antimicrobial,

in towelette, spray or liquid form

7. Standard Commercial Sharps container, fixed & Portable

8. Bio-hazard bags of identifiable color or markings or both

9. Disinfectant solution for cleaning equipment

10. N95 or N100 respiratory protection masks

114. Medications and drugs specified in the standard

operating procedures approved by the medical director that

the ambulance service provider reports to and included

in the plan approved by the department of Health services.

115. An automatic, semiautomatic or manual defibrillator for

use on adults and pediatric patients as specified in the

standard operating procedures approved by the medical

director that the ambulance service reports to and included

in the plan approved by the department of health services,

with appropriately sized defibrillation or conduction pads. This

paragraph applies to all in-service ambulances.

116. Fire extinguishers. Two, cab compart or in the body

reachable from outside the vehicle and one in the patient

compartment. The mounting bracket shall be a stable design.

117. 2 Portable, battery operated lights

118. 3 Reflectors or three noncombustible red light sticks

with a minimum of one-hour service duration.

Unless the ambulance routinely responds with or is an agency

that provides extrication assistance, the ambulance shall carry

the following equipment or its equivalent:

II

III

STATUTE

309.24(1)(jm)

309.24(1)(k)

309.24(1)(km)

309.24(1)(l)

309.24(1)(lm)

309.24(1)(m)

309.24(1)(n)

309.24(1)(o)

309.24(1)(p)

309.24(1)(pm)

309.24(1)(q)

309.24(1)(qm)

309.24(1)(qr)

309.24(1)(r)

309.24(1)(t)

309.24(1)(a)

309.205(1)(a)

309.205(1)(d)

309.205(1)(e)

III-AD

OK

NOT

OK

#

ITEM

STATUTE

119. Tools (Optional)

309.205(2)

(a) One 12-inch adjustable wrench.

(b) One screwdriver for slot head screws.

(c) One Phillips screwdriver.

(d) One hacksaw and 12-inch blades.

(e) One 10-inch locking grip pliers.

(f) One 16 oz. hammer.

(g) One 24-inch wrecking bar.

(h) Impact resistant eye protection.

(i) One pair of leather gloves.

(j) One roll of 2-inch duct tape.

(k) A spring loaded center punch.

120. Small hand tools shall be stored in an easily

309.205(3)

accessible area.

121. The vehicle shall be in safe operating condition.

309.207(1)

The vehicle and all required vehicle equipment shall

be functional and operable when the vehicle is in service.

122. All equipment shall be maintained in full

309.207(2)

operating condition, in good repair and be free from

rips, tears, holes, grease, dirt and other offensive

matter and shall not be carried beyond expiration dates.

123. All equipment carried in an ambulance must be

309.207(3)

securely stored so that, in the event of a sudden

stop or movement of the vehicle, the patient and all

occupants are not injured by moving equipment.

124. DOT Inspection, off year

309.207(4)

125. Safety Belts

309.209(1)(a)

126. Child Restraint System

309.209(1)(b)

Ambulances Staffed with EMTA, EMTI & EMTP may carry the equipment below

based on a services scope of practice, approved protocols and required by training

approved by the medical director the ambulance service provider reports to.

Ambulances staffed with advanced emergency medical technicians and emergency

medical technician- intermediates shall be equipped with the following:

127. Sterile intravenous infusion agents, in plastic

309.24(2)(a)

containers, with necessary IV starting equipment,

including an assortment of appropriately sized

adult and pediatric IV catheters, including small

sized catheters to at least 24 gauge.

128. Electrocardiogram monitor with acquisition

309.24(2)(b)

and transmission

129. Electrocardiogram monitor 12, 15 or 18 lead

309.24(2)(c)

with acquisition and transmission.

130. 2 or more intraosseous needles

309.24(2)(d)

131. Prepackaged medications, drugs and solutions

309.24(3)(c)

specified in the standard operating procedures

approved by the medical director that the

ambulance service provider reports to and the

department of health services.

In addition to the medical and surgical equipment specified in subs. (1) and (2),

ambulances staffed with emergency medical technician - intermediates may carry

the equipment below based on a services scope of practice, approved protocols and

with training approved by the medical director that the ambulance service provider

reports to. Ambulances staffed by paramedics shall carry the following:

132. Electrocardiogram monitor with interpretation.

309.24(3)(a)

133. Electrocardiogram monitor 12, 15 or 18 lead

309.24(3)(b)

with interpretation.

134. Medications and drugs specified in the

309.24(3)(c)

standard operating procedures approved by the

medical director that the ambulance service provider

reports to and the department of health services.

135. Expired medications, drugs, fluids, solutions or containers

309.24(4)

136. Tests or maintenance as recommended or

309.24(5)

required by the original equipment manufacturer

on all medical equipment carried.

OK

NOT

OK

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