Patient Care / In-Charge

Patient Care/In Charge

Patient Care Provider *

Patient Care Provider

Driver/Operator Name *

Driver/Operator Name

Shift Location *

Unit Number *

Vehicle Number *

Time

Date

Stretcher: *

Cardiac Monitor Self Test: *

Cardiac Monitor 12 Lead Ready: *

Cardiac Monitor AED Pads Pedi and Adult : *

Cardiac Monitor ETCO2 Supplies and Spare Battery: *

CPAP w/ 2 Masks : *

Autovent Complete with 2 Circuits/ 2 Peeps: *

Intubation Kit Complete and Lighting w/ ET Tubes: *

Drugs (proper quantity and current, stored according to policy and FDA recommendations): *

Both Suctions Operable: *

Airway Supplies (per supply list): *

Portable Suction Functioning (Place a gloved finger over the port to ensure it can provide addequate suction/max mmHg)

If you are human, leave this field blank.