Ambulance Inspection Form
S.No. Vehicle Details
1 Make
2 Year and Model
3 Registration Number
4 Chassis Number
Statutory Documents Date of Certification Certification Due Date
5 Fitness
6 Insurance
7 Pollution
8 Quaterly Tax
Vehicle condition Status Remarks
(Good & working, Needs Minor
repairs, Needs major repairs)
9 Interior, Flooring and FRP
10 Doctors/ EMT seat with seat belt
11 Patient's attender seat with seat belt
12 High intensity blinkers side
13 Focus light / Headlights
14 Indicators
15 Integrated electric siren and public addressing
16 Engine condition- Noise & Smoke
17 Radiator condition-Blockage & Coolant leaks
18 Steering Type and condition-Noise/wobble &
19 Vehicle Battery condition
20 Braking system & parking brakes
21 Suspension condition- Wobble, drag, Bouncy
22 Alternator condition
29 Self starter condition
30 Gear Box condition- check functioning of all
31 Clutch condition
32 Head Racks and Cupboards
33 Inverter and battery condition
34 Tyres & stepney
35 Vehicle dashboard & instrument cluster
36 Wash Basin (if applicable)
37 Air Condition & electrical sockets
38 Interior & Exterior check for Dents / Panels /
Logos
39 Stretcher type ( Manual/auto loading etc) &
condition
40 Wheel chair type (foldable, fixed) & condition
41 Oxygen panel & lines
Oxygen Cylinder Setup Status Remarks
42 Cylinder's with Flow meter and Humidifier
43 D-Type
44 B-Type
45 A-Type
Other Tools Status Remarks
46 Jack
47 Jack Rod
48 Pana
49 Wrench
50 MEDICAL EQUIPMENTS (ANEXURE)
Remarks
Handed Over By- Received By-
Company: Company:
Employee: Employee:
Designation: Designation:
Signature with Date: Signature with Date:
