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