36C26219R0102-003.docx

D.2 ATTACHMENT #2: PRE-AWARD SURVEY CHECKLIST

PRE-AWARD SURVEY CHECKLIST

Vehicle Number

Year of Gurney Van

Registration (Check for Current California Registration)

Yes or No

Miles on vehicle

A. GURNEY VAN VEHICLE (INTERIOR)

1. Interior condition

a. Heater (Operational)

b. Air Conditioner (Operational)

c. Safety restraining straps (to insure Gurney Vans do not move during transport)

d. Adequate first aid supplies

e. Fire Extinguisher

f. Appropriate road emergency warning equipment

g. Safety devices to load/unload passengers

B. GURNEY VAN VEHICLE (EXTERIOR)

1. Exterior condition

a. Headlights (Operational)

b. Tail lights (Operational)

C. ADDITIONAL FEATURES OF VEHICLES

a. Maximum capability to transport patients with weight capacity of 650 lbs

b. Safety devices to load/unload passengers

c. Ability to accommodate and transport all patients in lie-down position regardless of weight or size

d. Seats available for patient’s attendant

e. Ability to accommodate patients with more than two pieces of luggage

f. Ability to accommodate medical equipment and devices

g. Safety Equipment (Five Pound Fire Extinguisher, First Aid Kit)