Title Page
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Date
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Vehicle: select one.
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Your name.
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Previous shift EMT:
- ARMITAGE, K
- AUSTIN, B
- BAIER, D
- BRYANT, J
- COFFEE, J
- DEACON, K
- HERON, K
- HYATT, S
- JULIAN, D
- LUSHER, A
- MASTROGIUSEPPE, N
- MCKNIGHT, M
- MELZER, J
- MESSIER, J
- MILLER, C
- MILLER-EVANS, T
- PAPPAS, P
- SKIDMORE, J
- SMITH, B
- SUMNER, T
- WASHINGTON, F
- YANCHUNIS, A
Exterior damage check.
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Take photo if needed.
Interior: cab area check.
Interior: patient compartment check.
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Take photo if needed.
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Miscellaneous All supplies present? <br><br>Flashlight - 3 suction wall canisters w/ tubing & yankauer - 2ea. Air / O2 flow meters - Gloves (Small Medium Large) - Remotes - EPCR cable<br>
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Sealed Cabinet # 1 All supplies present?<br><br>4X4s <br>Pressure infuser <br>Sphygmomanometer <br>ECG Electrodes (neo/ped) <br>Thermometers <br>Spare BP cuffs (Propaq/Philips) <br>
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Next expiration date.
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Sealed Cabinet # 2 All supplies present? <br><br>Two Liter bags: NS <br>Two Liter bags: ½ NS <br>Two 500cc bags: D5 0.9% NS <br>Two 500cc bags: D10W <br>Two Liter bags: D5 ¼ NS <br>Two Liter bags: D5 ¼ NS 20K <br>Two Liter bags: D5 ½ NS <br>Two Liter bags: D5 ½ NS 20K <br>
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Next expiration date.
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Sealed Cabinet # 3 All supplies present? <br>A) Umbilical Catheter Kit - 1 Gastroschesis bag <br>B) Heat / Cold packs - Neo Cooling pack <br>C) IV Infusion Sets - Transducer <br>D) Four Sterile Gowns <br>E) Two Pack Non-sterile gowns <br>F) Two Transwarmer mattresses <br>G) Spare Stethoscopes <br>H) Two Liter bags: D5 NS 40K <br>I) Two Liter bags: NS 40K <br>J) Surgical Masks - N95 respirators - Eye shields <br>
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Next expiration date.
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Sealed Cabinet #4 All supplies present? <br><br>Two Turkel Chest Tube Trays <br>Urinals <br>Bedpans <br>
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Next expiration date.
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Sealed Cabinet # 5 All supplies present? <br><br>Aspen collars (P1-5, Adult small, reg, tall) <br>Spare Suction Supplies (canisters and tubing) <br>Behavioral Restraint Bag<br>
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One O2 E-cylinder - Full (2000psi minimum) and present?
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Two O2 D-cylinders - Full (2000psi minimum) and present?
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One Air E-cylinder - Full (2000psi minimum) and present?
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Cabinet # 6 / Storage Area All supplies present? <br><br>Nitric Bag (plugged in and charging) <br>Spare RT bag <br>
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Sealed Cabinet # 7 All supplies present? <br><br>22mm Vent Circuit, 15mm Vent Circuit, Neo Vent Circuit <br>Sterile Suction Cath (2x6fr, 2x8fr, 2x10fr, 2x14) <br>Nasal Cannulas: Two NEO, Two PEDI, Two ADULT <br>Non-Rebreather Masks: adult and pedi <br>Two Ventimasks<br>BVMs (infant, ped, adult)<br>Neo-Tee (w/ infant and neo masks) <br>Two Nitric kits<br>
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Sealed Cabinet # 8 All supplies present? <br><br>Sheets <br>Baby Blankets (in warmer - warmer OFF) <br>Big Blankets <br>Towels <br>Gowns <br>Cleaning spray/wipes <br>Bleach Wipes<br>
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Drawer A All supplies present? <br><br>Assorted Syringes (20cc, 30cc, 60cc) <br>Med labels <br>Alcohol Preps <br>Rapid Fill Connector <br>Dispensing Pins <br>Syringe Tubing (filtered and non-filtered) <br>EZ Lubricating Jelly<br>
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Drawer B All supplies present? <br><br>Assorted Syringes (1cc, 3cc, 5cc, 10cc) – 18g needles - Filter Needles<br>
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Drawer C / Action Area All supplies present? <br><br>4x4s <br>Assorted Syringes <br>Flushes <br>18g needles <br>Med Labels <br>Alcohol Preps <br>Hand Sanitizer <br>Emesis Bags <br>24g IV Catheters <br>Tape
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Drawer D All supplies present? <br><br>Bio hazard trash - Sharps
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Drawer E All supplies present? <br><br>Two Pedi and two adult yankaurs <br>NG/OG Syringes <br>SpO2 probes
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Drawer F All supplies present? <br><br>Truck Checks - paper format <br>Spare Forms <br>Spare monitor paper (Philips/Propaq) <br>Code Sheet Book <br>Drug Reference <br>DVDs
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Drawer G All supplies present? <br><br>Diapers & Wipes <br>Bio Bags <br>Bolts <br>Seals<br>Pat ID/Allergy bands <br>O2/Air regulator <br>ratchet straps
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Phillips Defibrillator OPS check - Passed (select YES or NO to indicate pass or fail or NA if not Monday)
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Drug Refrigerator - temperature between 38-42*F? <br><br>
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Yellow Code Bag present and sealed?
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Next expiration date:
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Black Med Bag present and sealed?
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Next expiration date:
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Ambulance safe to operate? If not, please explain why?
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I herby affirm that all information listed is accurate and correct as indicated in this report.
