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  • Ambulance CheckList Form

    Transféré par

    Hervian Lanang
    387 vues4 pages
    This document is an ambulance checklist used to inspect ambulances on a weekly basis. It contains 20 items to check including the ambulance exterior, front cabin, rear cabin, wheels/tires, engine fluid levels, and emergency equipment. For each item, inspectors mark whether the check was completed or incomplete for that week. The checklist is signed by the inspecting driver and an HSE officer.

    Description originale:

    Ambulance

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    This document is an ambulance checklist used to inspect ambulances on a weekly basis. It contains 20 items to check including the ambulance exterior, front cabin, rear cabin, wheels/tires, engine fluid levels, and emergency equipment. For each item, inspectors mark whether the check was completed or incomplete for that week. The checklist is signed by the inspecting driver and an HSE officer.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme XLSX, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    387 vues4 pages

    Ambulance CheckList Form

    Transféré par

    Hervian Lanang
    This document is an ambulance checklist used to inspect ambulances on a weekly basis. It contains 20 items to check including the ambulance exterior, front cabin, rear cabin, wheels/tires, engine fluid levels, and emergency equipment. For each item, inspectors mark whether the check was completed or incomplete for that week. The checklist is signed by the inspecting driver and an HSE officer.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme XLSX, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 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

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