COVID-19 Ambulance Check Form
Evaluation Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Country
Organization Name
Organization Type
Government
Private
Volunteer
Other
Ambulance Material Checklist
Rows
Yes
No
Needs Renewal
Notes or Comments
Medical Masks
1
2
3
Scrubs (White Suits)
4
5
6
Medical Latex Gloves
7
8
9
Eye-Pro
10
11
12
Knee Protection
13
14
15
Body Armor
16
17
18
Seat Belts
19
20
21
Helmets
22
23
24
Isolation PPE
25
26
27
Jump Bag
28
29
30
Bag Valve Mask (BVM)
31
32
33
Blood Pressure Gauges
34
35
36
Stethoscopes
37
38
39
Thermometers
40
41
42
Medical Tapes
43
44
45
Safety Triangle
46
47
48
Communication Equipment / Radio
49
50
51
Flashlights and Blankets
52
53
54
Tissue Paper
55
56
57
Trash Bag / Plastic
58
59
60
Portable Oxygen
61
62
63
Oxygen Supplies Accessories
64
65
66
Maternity Pack
67
68
69
Advanced Life Support (ALS)
70
71
72
Basic Life Support (BLS)
73
74
75
Cardiopulmonary resuscitation (CPR)
76
77
78
Emergency Medical Dispatcher
79
80
81
ECG Monitor with Defibrillator
82
83
84
Incubators
85
86
87
Transport Ventilator
88
89
90
Infusion Pumps And Syringe Pumps
91
92
93
Heamogulcometer
94
95
96
Stretcher Trolley
97
98
99
Patient Shifting Rolls
100
101
102
Suction unit
103
104
105
Trauma/ spinal Board
106
107
108
Cervical Collar
109
110
111
Do the paramedics know how to Detect – Isolate - Report of COVID-19?
Yes
No
Do the paramedics know what to do if a patient screens positive for COVID-19 by phone?
Yes
No
Do the paramedics know what to do if a patient screens positive for COVID-19 on screen?
Yes
No
Evaluator Information:
Name
First Name
Last Name
Job Title
Works for
Email
example@example.com
Signature
Submit
Should be Empty: