Title Page
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MoMo Unit Number
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Rescue Unit
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Officer-Paramedic
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Driver-Paramedic/AEMT/EMT
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Date & Time
Mechanics
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Mileage
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Fuel level
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Oil Level
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Def fluid level
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Lights and Siren- functioning correctly?
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Head Lights, Scene Lights, Brake Lights, Blinkers, Back up alarm/camera, Patient compartment electronics- functioning correctly?
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Tires- do they appear to be in good condition?
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Stretcher and Mount- functioning properly?
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Windshield Wipers- do they appear to be in good condition
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Inverter and Outlets- functioning properly?
Damage to Report
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Do you see any damage that appears new or you are unsure of? Truck or Equipment?
Outside Compartments
Compartment 1 ( Behind Driver)
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Main O2 Level
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Stair Chair Clean, functioning, battery charged?
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Broom?
Compartment 2 ( Drivers side next to Main O2)
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Drivers Tactical Gear (Vest and Helmet)
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Fire Extinguisher
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Toolbox
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Rescue Blanket
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Driver Tactical Gear Helmet and Vest
Compartment 3 ( Drivers Side Rear)
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Lucas- Suction cup, head strap, backboard? Clean/Battery Charged?
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LSB with Straps x2
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Pedi LSB
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C-Collars 5 Adult, 5 Child, 2 Infant
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Head Blocks - 5
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Arm/Leg Splints 2 of each size
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Adult & Pedi Traction Splint. Clean with all pieces.
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KED- Clean and with all pieces
Compartment 4 (Passenger side compartment)
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Passenger Tactical Gear Helmet and Vest
Patient Compartment
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Stretcher- Clean with sheet, Straps ( Shoulder/Chest straps 2 leg straps) in good condition- not ripped or frayed, charging?
- Yes
- No
- N/A
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Stretcher O2- PSI
Compartment A
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Fixed Suction Unit with canister, tubing , and catheter
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Med Box A&B Locked - Keys with Primary Medic
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Jump Bag
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Portable Suction with canister, tubing, yanukers
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Linen- 10 Sheets, 5 blankets
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Trash Can- emptied
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Airway Bag with portable O2
Captain's Chair
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2-Spare O2 Bottles- Sealed and secured
Compartment B
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BVM 2 of each Adult, Pediatric and Infant<br>1 Set of NPA 20,24,28,30,32,34<br>1 Set of OPA 00,0,1,2,3,4,5,6<br>3 of each size i-gel<br>ETT 2 of each size, 2.5 - 9.0<br>5- Bougies<br>5- In-Line ETCO2 monitors<br>Laryngoscope handle with blades and spare batteries- Mac 1-4, Miller 1-4<br>ET Holder 5 adult and 5 pediatric
Compartment C
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10-Adult Nasal Cannula <br>10- Adult Nasal Cannula with ETCO2<br>10- Adult NRBM<br>10- Adult Neb with mask and tubing<br>
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5- Pedi Nasal Cannula<br>5-Pedi NRBM<br>5- Pedi Neb with mask and tubing<br>5- O2 Supply Tubing
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2 of each- Sterile Suction Catheters 6,8,10,14 fr<br>2- Suction Canisters<br>2- Ridgid Yaunkers<br>2- Suction Tubing<br>2- Portable suction Canisters
Compartment D
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2 Sets of restraints 4-ankle, 4-wrist<br>10-emesis bags<br>10- packs of electrodes<br>2- Adult Defibrillator pads<br>2- Pedi Defibrillator pads
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Compartment E
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5- 1000mL NS<br>5- 1000mL LR<br>5- 100ml NS<br>5- 10gtt sets<br>5- 60gtt sets
Shelf A
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IV Tray - <br>10 each IV Catheter 14,16,18,20,22,24<br>10 INT Caps<br>10 NS Flush<br>20 Band-Aids<br>20 Tegaderm<br>10 Tourniquets<br>20 Alcohol Preps<br>10 10cc Syringes<br>10 5cc Syringes<br>10 3cc Synringes<br>10 1cc Syringes<br>10 4x4s<br>2 Rolls 1in Tape<br>Glucometer with 1 Bottle of Strips<br>20 Lancets
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1 Fluid Warmer with dated 1000ml IV bags no more than 2 weeks old
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Main O2 Flow meter (Green tree attached)
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Gloves 1 box each size S, M, L XL
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Resource Books. Protocols, CBRNE.. Etc.
Shelf B
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Cardiac Monitor- Self Test Passed?
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Cardiac Monitor Supplies:<br>Limb Lead Cables<br>SaO2 Cable<br>B/P Cuff Pedi, Adult, Large Adult<br>12 Lead Cables<br>Roll of Printer Paper<br>Defibrillation Cable<br>2 Sets Adult/Child Defib Pads<br>1 Set Infant Defib Pads<br>3 Pouches Electrodes<br>Defib Test module<br>Inline ETCO2 <br>High Flow O2 NC with ETCO2<br>Spare roll of printer paper<br>2 Charged batteries
Compartment F
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10 Triangular Bandages<br>2 Trauma Dressings 10x30<br>2 Packs 4x4s<br>10 5x9s<br>10 Rolls 3 Inch Kling<br>10 Rolls 6 Inch Kling<br>5 ACE Wrap 3 Inch<br>5 ACE Wrap 6 Inch<br>5 Petroleum Guaze 4x4<br>5 Rolls 2in Silk Tape<br>5 Rolls 3in Silk Tape <br>2- DART Decompression Needles<br>5- Chest Seals
Compartment G
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Lucas- Clean, Charged and ready to go?
Compartment H & I
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2-OB Kit<br>Foil Swaddle<br>5 each Size N95 Masks<br>15 Surgical Masks<br>2 Safety Glasses<br>2- Burn sheets<br>2- 500mL bottles of sterile water
Bench
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Sharps Container - please replace when almost full.
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Bio-Hazard Trash- Empty
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Manual BP Cuffs Adult, Pedi, Infant
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Stethoscope
Under Bench Seat
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Pedi-Mate
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1 Ben Pan<br>1 Urinal<br>4 Splash PPE Kits<br>5 Small Redbags<br>2 Large Redbags<br>Large roll 6 mil plastic<br>2 Rolls Duct Tape
Inside of Cab
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US DOT Emergency Response Guide
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2 Safety Vests, one in each door
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CAD/MDT- functioning properly?
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Base Radio- operational?
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Ipad with charger- functioning properly?
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iphone with charger- functioning properly?
Supply Needs
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Please list any items needed for the rescue so we can order them from supply.
