Winchester EMS Daily Equipment and Vehicle Inspection

 Step 1 of 1

* Denotes a required field
Date*
 Date
*
*
*
*

GENERAL MAINTENANCE

Verify: Oil, Brake fluid, washer fluid/wipers, tires, exhaust system, windows/mirrors, marker lights, headlights high/low, fuel (add level below), gas card.
Body Damage*
Fluid Leaks?*
General Maintenance Problems?*
 
*

DRIVER COMPARTMENT

Check cab for contraband, was anything found?*
Verify: Turn Signals, brake lights, battery status, parking brake(HI IDLE), backup warning device, emergency lights/sirens, radio (9VHF/800), heating/Air Conditioning, Seats/safety belts, clipboard w/forms, rear load lights.
*
 

OUTSIDE COMPARTMENTS

*
 

PATIENT COMPARTMENT

Verify: [PT Compartment Lights], [heating/Air Condition], [Flashlight], [On-Board suction w/tips], [Oxygen Equipment (5 each: Adult N/C, nonreabreathers, nebulizers)], [Peds and infant (2 each, nonrebreathers)], [Cot w/3 straps/pillow/clean linens], [Extra linens for at least 1 cot change], [Extra pillow], [Sharps container], [Protocols], [OP, NP airways (2 each-adult, child, infant)], [Combi Tube (2)], [BVM w/masks (1 each-adult, child, infant)], [ET Tubes (2 each 3-9)], [IV Fluids (1000cc) bags(5)], [Administration sets (5)], [Sterile gauze pads 3x3 or larger (50)], [Kerlex (5 rolls)], [Vaseline gauze (4)], [Triangular bandages (4)], [Adhesive tape(2)], [Bandage Shears], [Trauma Dressings (2 minimum)], [Burn Sheets (2 minimum)], [Bulb syringe - individually wrapped (2 minimum)], [Sterile water (2)], [OB kit (1)], [Gowns (2)], [Face masks w/shields (2)], [Gloves (1 box each size)], [Anti-bacterial hand cleaner], [BP cuffs (all sizes)], [Stethoscope (adult & peds)], [Pocket mask (1)], [Biohazard bags], [Heart monitor], [BLS box], [Airway box], [Drug box], [Glucometer w/strips],
*
 
*
*
*
*
*
 
*
 

MEDICATIONS (Minimum Required)

Verify: [Adenmocard 30mg], [Aminodarone 450mg], [Aspirin 1 bottle], [Albuterol 6 vials], [Atropine 3mg], [Atrovent 6 vials], [Benadryl 100mg], [Brethine 2mg], [Calcium Chloride 1000mg], [Calcium Gluconate 100mg], [Cardizem 100mg], [Epinephrine 1:100 1 multidose], [Epinephrine 1:1000 5mg], [Glucagon 2 vials], [Haldol 20mg], [Instant Glucose 2 tubes], [Dopamine 1600mcg] [Lasix 120mg], [magnesium Sulf. 4mg], [Narcan 2mg], [Nitro spray 1 bottle], [Nitro paste 1 tube], [Vasopressin 40 units] [Sod Bicarb 50 meq], [Solu-medrol 125mg], [Zofran IV 8mg], [Compazine 10mg], [Lidocaine Inj 300mg], [Dextrose 50% 50gms], [Lidocaine premix 4mg/cc bag], [Racemic EPI 5 vials], [Tetracain 1 bottle], [Zofran ODT 16mg]
*
 

NARC BOX

*
*
*
*
 

BY SUBMITTING THIS FORM, YOU ARE VERIFYING THAT ALL INFORMATION PROVIDED IS ACCURATED AND COMPLETE?

Contact Us

113 E. Washington St.
PO Box 408
Winchester, IN 47394
Get Directions
  • Phone: 765-584-6845
  • Fax: 765-584-6171
  • Staff Directory