C-GOPC

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

C-PAP Checklist

• 1- C-PAP Unit & Case

  Yes

  No

  N/A

• 1- Sealed package of tubing

  Yes

  No

  N/A

• 1 each- Small/Medium/Large Face pieces

  Yes

  No

  N/A

• 1 E Cylinder with C-PAP connection

  Yes

  No

  N/A

• PSI of E-Cylinder

• OLD C-PAP TAG NUMBER

• NEW C-PAP TAG NUMBER

Glucometer Check

• Minimum of 5 Lancets

  Yes

  No

  N/A

• 5 Alcohol Wipes

  Yes

  No

  N/A

• Minimum 10 Glucometer Strips

  Yes

  No

  N/A

• Glucometer control solution test (range on side of strip bottle)

  Passed

  Failed

• Enter glucometer test solution reading

• Enter test solution range

Portable Suction

• Suction working properly

  Yes

  No

  N/A

• Charged Batteries

  Yes

  No

  N/A

• Batteries rotated

  Yes

  No

  N/A

• Any Damage?

  Yes

  No

  N/A

Crew Signatures

• Add signature

  Sign

• Add signature

  Sign