Equipment	Present	Not Present	Need for New (Specify Number)
EKG device	Yes/No	Yes/No	_______
Biphasic defibrillator with monitor	Yes/No	Yes/No	_______
Biphasic defibrillator with monitor and transcutaneous pacemaker	Yes/No	Yes/No	_______
Biphasic defibrillator with monitor, transcutaneous pacemaker, and capnography option	Yes/No	Yes/No	_______
Aspirator—portable	Yes/No	Yes/No	_______
Portable mechanical respirator with oxygen cylinder	Yes/No	Yes/No	_______
Portable mechanical respirator with oxygen cylinder with CPAP mode option	Yes/No	Yes/No	_______
Set for cardiopulmonary resuscitation (laryngoscope with at least 3 blades of different sizes, endotracheal tubes min. 5 different sizes, self-expanding resuscitation bag, oronasal masks min. 3 different sizes, oropharyngeal tubes min. 3 different sizes)	Yes/No	Yes/No	_______
10-L oxygen cylinder	Yes/No	Yes/No	_______
Portable oxygen cylinder	Yes/No	Yes/No	_______
Trauma care set (bandaging material, straight and curved forceps, Esmarch’s bandage of greater length, scissors for cutting clothes)	Yes/No	Yes/No	_______
Vacuum mattress	Yes/No	Yes/No	_______
Vacuum splints	Yes/No	Yes/No	_______
Collars for immobilization of the cervical spine	Yes/No	Yes/No	_______
Kramer splints	Yes/No	Yes/No	_______
Vest for immobilization and extraction of the injured (KED)	Yes/No	Yes/No	_______
Long spinal board with head immobilizers and body fastening straps	Yes/No	Yes/No	_______
Longitudinally collapsible scoop stretcher for spinal injuries and polytrauma (“Ferno stretcher”)	Yes/No	Yes/No	_______
Infusion solution warmer	Yes/No	Yes/No	_______
Refrigerator for cooling infusion solutions	Yes/No	Yes/No	_______
Transport refrigerator for therapeutic hypothermia equipment	Yes/No	Yes/No	_______
Thrombolytic therapy medications (Streptokinase/Metalyse/Actilyse)	Yes/No	Yes/No	_______
Urgent conicotomy set	Yes/No	Yes/No	_______
Set for intraosseous medication administration	Yes/No	Yes/No	_______
Birth set	Yes/No	Yes/No	_______
Pulse oximeter	Yes/No	Yes/No	_______
Central vein puncture set	Yes/No	Yes/No	_______
Chest decompression set	Yes/No	Yes/No	_______
Burn dressings	Yes/No	Yes/No	_______
Reflector lamp	Yes/No	Yes/No	_______
Protective helmet with forehead flashlight for each team member	Yes/No	Yes/No	_______
Protective reusable gloves	Yes/No	Yes/No	_______
Protective glasses	Yes/No	Yes/No	_______
Fixed radio station in the ambulance	Yes/No	Yes/No	_______
Handheld radio station	Yes/No	Yes/No	_______
Ultrasound	Yes/No	Yes/No	_______