EMS Daily Checkoff

Date

Mileage *

Oil Change *

Laptop Number *

Portable O2 PSI *

Main O2 PSI *

Tablet Number if Applicable.

Crew Member 1 *

First Name Last Name

Crew Member 2 *

First Name Last Name

Radios

Main Portable Hear Zipit

Unit # *

Fuel *

Tire Condition *

Fluids Checked *

Shift Supervisor *

Jump Bag # *

Cardiac Monitor # *

Batteries Left in Monitor *

Unit Cleaned Outside? *

Unit Cleaned Inside? *

Unit Stocked at Start of Shift? *

Required Items Present *

	Yes	No	Worn	Leaks(If Applicable)
12 Lead Cables
BP Cuff Lines
3 Lead Cables
ETCO2 Lines
Monitor Paper
Combo Defib Pads
Therapy Cable
Pulse Ox Cable
Pulse Ox
3 BP Cuffs
Stethoscope
Glucometer
Portable Regulator
Power Inverter

If You answered NO, WORN, or LEAKS in any of the above table please notify your team leader or manager at the start of your shift.

Immobilization

	On Unit
CID(2)
Adult CC(4)
Ped CC(1)
Baby CC(1)
LSB w/ straps(2)
Ped LSB(1)
AOA Arm(2)
AOA Leg(2)
Pedimate(1)
KED(1)
Straps(3)
Restraints(set)(2)
Adult Traction(1)
Ped Traction(1)

Oxygen/Airway

	On Unit
NR(4)
NC(4)
Simple(3)
NR Ped(3)
NC Ped(3)
Simple Ped(3)
Tubing(3)
Adult BVM(2)
Ped BVM(2)
Infant BVM(1)
Combitube(1)
Main O2(1)
Portable O2(1)
Spare Portable(1)

Suction

	On Unit
Main Suction(1)
Portable Suction(1)
Suction Tubing(2)
Yankauer(2)
6fr(2)
10fr(2)
14fr(2)
18fr(2)
Convenience Bag(2)
Emesis Basin(2)

Bandaging

	On Unit
2" Kling(4)
4" Kling(4)
6" Kling(4)
Sterile 4x4(25)
Bulk NS 4x4(1)
4" Ace(2)
6" Ace(2)
5x9(12)
Trauma Dressing(2)
Burn Sheet(2)
Eye Pads(2)
Vaseline Gauze(4)
Triangle Bandage(3)
2" Cloth Tape(2)
2" Clear Tape(2)
OB w/ swaddler(1)

Disposables

	On Unit
Med Gloves(1)
Lg Gloves(1)
XL Gloves(1)
Sm HEPA(2)
Lg HEPA(2)
Mask w/ Shield(4)
Isolation Kit(2)
Bio Bags(5)
Sharps(1)
Cold Pack(2)
Hot Pack(2)
Sterile H2O(8)
Rescue Blanket(2)
Urinal(1)
Bedpan(1)
Alcohol Soap(1)

Jump Bag

	On Unit
Sterile 4x4(5)
12 Pack NS 4x4(1)
5x9(3)
4" Kling(2)
6" Kling(2)
Vaseline Gauze(3)
2" Cloth Tape(1)
2" Clear Tape(1)
Adult BVM(1)
Stethoscope(1)
Pulse Ox(1)
Large BP Cuff(1)
Adult BP Cuff(1)
Ped BP Cuff(1)
Trauma Shears(1)
Penlight(1)
NC-Adult(1)
NR-Adult(1)
Glucometer(1)
OPA 1-6(1ea)
NPA 16,20,24,28,32,36(1ea)
NS 500ml(1)
10gtt Set(1)
IV Cath-14,16,18,20,22(1ea)
Instant Glucose(1)

ALS

	On Unit
Monitor
3 Lead Cable
12 Lead Cable
Adult Electrodes(12)
Ped Electrode(3)
Defib Pads A&P(1ea)
3.0 ET(1)
4.0 ET(1)
5.0 ET(1)
7.0 ET(1)
8.5 ET(1)
#2 Mac(1)
#3 Mac(1)
#4 Mac(1)
#1 Miller(1)
#2 Miller(1)
#3 Miller(1)
Stylet- Adult(1)
Stylet- Ped(1)
Laryngoscope Handle(1)
Tube Tamer(1)
10cc Syringe(1)
KY(4)
Magill Forceps(1)
Magill Forceps- Ped(1)

IV Box

	On Unit
LR 1000cc(2)
NS 500cc(3)
10gtt drop set(5)
14Ga IV Cath(2)
16Ga IV Cath(2)
18Ga IV Cath(4)
20Ga IV Cath(4)
22Ga IV Cath(4)
IO Cath(1)
Alcohol Preps(20)
Touniquet(5)
10cc Syringe(2)
18Ga Needles(2)

Misc

	On Unit
Clipboard(1)
10lb ABC Extiguisher(1)
Blankets(2)
Sheets(4)
Pillow Case(4)
Towels(4)
Flashlight(1)
EMR Guide(1)
Terrorism job aid(1)
Care Bear(1)
Pillow(1)

SC Items not on above list for DHEC

Explanation of missing items and condition of unit.

Crew Member 1

Clear

Crew Member 2

Clear

Laptop Number

Signature

Clear