Form EMS 4016 at a glance
What it is: The Ambulance Inspection Advanced Life Support (ALS) form contains the vehicle roadworthiness requirements and equipment required for a permitted ambulance authorized by sections 4766 of the Ohio Revised Code (R.C.) and Ohio Administrative Code (O.A.C.).
Who signs: Under inspection data, enter the inspector name and the date of inspection.
A filled-in Form EMS 4016 example: an inspector fills out a renewal inspection
How to fill out Form EMS 4016, box by box
Service name, service code and reason for inspection
Enter the service name and the service code (6 digits).
Under reason for inspection, check new service, renewal, new vehicle, reinspection, unannounced or temporary permit number.
Description of vehicle and level of service
Under description of vehicle, enter the vehicle decal number, service vehicle number, odometer, vehicle identification number (VIN), year, make, model and license plate number; check EMS, temporary or out of state.
Under level of service when inspected, check intermediate or paramedic.
Inspection data and violation notification
Under inspection data, enter the inspector name and the date of inspection.
Mark YES, NO or N/A on each line: Was a Violation Notification issued for this vehicle? Is the copy of the Violation Notification attached to this form? Is a reinspection required?
A. LIGHTING and B. TIRES / WHEEL / BRAKES
In A. LIGHTING, mark YES, NO or N/A on each line from .01 High and Low Beam Headlights operational to .11 Emergency Lighting Operational (Only if entire system is out); line .04 Dashboard lights and interior lights operational is shown with (If all lights are out).
In B. TIRES / WHEEL / BRAKES, mark YES, NO or N/A on each line from .01 Tread depth 1/16 inch minimum on all tires to .05 Emergency/parking brake operational.
C. STEERING / SUSPENSION to G. OXYGEN EQUIPMENT
In C. STEERING / SUSPENSION, mark YES, NO or N/A on each line from .01 Steering shaft secure; no excessive play to .05 Air ride suspension properly inflates/deflates.
In D. WINDSHIELD / WINDOWS / MIRRORS, mark YES, NO or N/A on each line from .01 Windshield without breach, unobstructed to .04 Rear view mirrors without breach.
In E. WARNING DEVICES, mark YES, NO or N/A on each line from .01 Horn operational and audible to .03 Siren operable and audible.
In F. MISCELLANEOUS, mark YES, NO or N/A on each line from .01 Driver and passenger safety belts operational to .16 Annual extinguisher maintenance check per OSHA.
In G. OXYGEN EQUIPMENT, mark YES, NO or N/A on each line from .01 Permanently installed main oxygen system (current hydrostatic testing) to .08 Nasal cannulas (Adult-Child) (2 each).
H. SUCTION EQUIPMENT to K. ISOLATION EQUIPMENT
In H. SUCTION EQUIPMENT, mark YES, NO or N/A on each line from .01 Permanently installed suction unit to .08 Suction bags (2 extra disposable liners or containers); .04 Soft tip suction catheter (2 sizes) 1 between 6.0 and 10 French and 1 between 12 and 16 French; .05 Sterile water and/or NS (4) minimum 1000 ML excluding IV solutions; .06 Sterile gloves (2 pair).
In I. AIRWAY EQUIPMENT, mark YES, NO or N/A on each line from .01 Oropharyngeal airway devices infant through adult (1) to .18 Supraglottic airway devices (adult/pediatric) (1)(2); .11 Pediatric Endotracheal Tubes is (1 ea. cuffed or uncuffed 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5) (1)(2).
In J. BLEEDING CONTROL / BURN EQUIPMENT / COMMERCIAL TOURNIQUET DEVICE, mark YES, NO or N/A on each line from .01 Adhesive dressing strips (10) to .08 Commercial Tourniquet Device (1).
In K. ISOLATION EQUIPMENT, mark YES, NO or N/A on each line from .01 Kits (4) OR to .09 Waterless hand cleaner.
In section H to section K, a line marked (1) is Per Medical Protocol and a line marked (2) is Per Medical Protocol/Requires Waveform Capnography.
L. IMMOBILIZATION EQUIPMENT to N. INTERMEDIATE - ONBOARD DEFINITIVE CARE EQUIPMENT
In L. IMMOBILIZATION EQUIPMENT, mark YES, NO or N/A on each line from .01 Extremity immobilization devices (board, air, vacuum, ladder, or equivalent) to .07 Stairchair and/or combo stairchair/folding cot (1).
In M. ADJUNCT EQUIPMENT, mark YES, NO or N/A on each line from .01 Trauma Shears (1) to .20 Age/weight appropriate pediatric restraint (1).
In N. INTERMEDIATE - ONBOARD DEFINITIVE CARE EQUIPMENT, mark YES, NO or N/A on each line from .01 Approved medications as shown on Ohio State Board of Pharmacy License/Addendum to .09 Needles (assorted sizes).
In section L to section O, a line marked (1) is Per Medical Protocol and a line marked (2) is Battery Tested and has up-to-date Service Records.
O. ALS - ONBOARD DEFINITIVE CARE EQUIPMENT and COMMENTS
In O. ALS - ONBOARD DEFINITIVE CARE EQUIPMENT, mark YES, NO or N/A on each line, .01 to .15, with .03 Monitor/defibrillator (with EKG Trace) external cardiac pacing capability (2) and .14 Intraosseous Needles or kit (1) (2).
Enter COMMENTS in the box.
More rules for Form EMS 4016
Violation of a bolded field results in automatic reinspection.
Sources
[1] Form EMS 4016 (8/22), Ambulance Inspection Advanced Life Support (ALS), Ohio Department of Public Safety, Division of Emergency Medical Services (the Official source link on this page).