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HOME
ABOUT US
STAFF
RESPONSE READINESS
SHIFT BOARD
PATIENTS
CONTACT US
CAREERS
JOB APPLICATION
MARKETING JOB APPLICATION
1st of the Month Check Off
1st of the Month Check-Off
1st of the Month Check-Off
First Name
*
(First Name)
Last Name
*
Last Name
Shift Location
*
Beaumont
Baytown
San Antonio
The Woodlands
Cypress/Katy
Houston
Corpus Christi
Clear Lake/ Webster
Kingwood
Dallas
Kingwood
Longview
College Station
Round Rock
New Braunfels
Time
12
1
2
3
4
5
6
7
8
9
10
11
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00
01
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42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Date
Unit Number
*
M-101
M-102
M-103
M-104
M-105
M-106
M-107
M-108
M-109
M-110
M-111
M-112
M-113
M-114
M-115
M-116
M-117
M-118
M-119
M-120
Vehicle Number
*
M-101
M-102
M-103
M-104
M-105
M-106
M-107
M-108
M-109
M-110
M-111
M-112
M-113
M-114
M-115
M-116
M-117
M-118
M-119
M-120
Last 4 of VIN
*
Adenosine 12mg/4ml OR 6mg/2ml (6 Required)
#REQ
# ON UNIT - Adenosine
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
EXP. DATE 17
EXP. DATE 18
EXP. DATE 19
EXP. DATE 20
EXP. DATE 21
EXP. DATE 22
EXP. DATE 23
EXP. DATE 24
EXP. DATE 25
Notes
Albuterol Sulfate UNIT DOSE 2.5mg/3ml (4 Required)
#REQ
# ON UNIT - Albuterol
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
EXP. DATE 17
EXP. DATE 18
EXP. DATE 19
EXP. DATE 20
EXP. DATE 21
EXP. DATE 22
EXP. DATE 23
EXP. DATE 24
EXP. DATE 25
Notes
Amiodarone 150mg/3ml (3 Required)
#REQ
# ON UNIT - Amiodarone
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
EXP. DATE 17
EXP. DATE 18
EXP. DATE 19
EXP. DATE 20
EXP. DATE 21
EXP. DATE 22
EXP. DATE 23
EXP. DATE 24
EXP. DATE 25
Notes
Anaphylaxis Kit
#REQ
# ON UNIT - Anaphylaxis Kit
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
EXP. DATE 17
EXP. DATE 18
EXP. DATE 19
EXP. DATE 20
Notes
Asprin 81mg (1 Required)
#REQ
# ON UNIT - Asprin
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
Notes
Atropine Sulfate 1mg/10ml (3 Required)
#REQ
# ON UNIT - Atropine Sulfate
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
Notes
Benadryl (3 Required)
#REQ
# ON UNIT - Benadryl
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
Notes
Dexamethasone 10mg/ml (3 Required)
#REQ
# ON UNIT - Dexamethasone
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
Notes
Dextrose 50% 25g/50ml (3 Required)
#REQ
# ON UNIT - Dextrose
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
Notes
Dopamine 400mg 1600 mcg/ml (premix )in D5W (1 Required)
#REQ
# ON UNIT - Dopamine
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
Notes
Epinepherine 1:1000 1mg/ml (2 Required)
#REQ
# ON UNIT - Epinepherine 1:1000
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
Notes
Epinepherine 1:10,000 1mg/10ml (2 Required)
#REQ
# ON UNIT - Epinepherine 1:10,000
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
Notes
Magnesium Sulfate 5mg/10ml (2 Required)
#REQ
# ON UNIT - Magnesium Sulfate
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
EXP. DATE 17
EXP. DATE 18
EXP. DATE 19
EXP. DATE 20
EXP. DATE 21
EXP. DATE 22
EXP. DATE 23
EXP. DATE 24
EXP. DATE 25
Notes
Naloxone (Narcan) 2mg/2ml (2 Required)
#REQ
# ON UNIT - Naloxone (Narcan)
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
Notes
Nitroglycerin (Nitrostat) 400mcq PER SPRAY OR TABLETS 0.4MG (1 Required)
#REQ
# ON UNIT - Nitroglycerin (Nitrostat)
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
Notes
Ondansetron (Zofran) 4mg/2ml (2 Required)
#REQ
# ON UNIT - Ondansetron (Zofran)
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
Notes
Oral Glucose 15g PER TUBE (2 Required)
#REQ
# ON UNIT - Oral Glucose 15g PER TUBE
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
Notes
Sodium Bicarbonate 50meq 1meq/ml (2 Required)
#REQ
# ON UNIT - Sodium Bicarbonate
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
Notes
Versed 2mg/2ml (2 Required)
#REQ
# ON UNIT - Versed 2mg/2ml
*
EXP. DATE 1
*
EXP. DATE 2
EXP. DATE 3
EXP. DATE 4
EXP. DATE 5
EXP. DATE 6
EXP. DATE 7
EXP. DATE 8
EXP. DATE 9
EXP. DATE 10
EXP. DATE 11
EXP. DATE 12
EXP. DATE 13
EXP. DATE 14
EXP. DATE 15
EXP. DATE 16
EXP. DATE 17
EXP. DATE 18
EXP. DATE 19
EXP. DATE 20
EXP. DATE 21
EXP. DATE 22
EXP. DATE 23
EXP. DATE 24
EXP. DATE 25
Notes
Signature
*
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