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Monthly EMS Inspection
Leave This Blank:
Unit ID:
*
Date:
*
Provider:
*
HFD ID:
*
EMS ID:
*
On-Duty Shift:
*
A-Shift
B-Shift
C-Shift
All expiration dates should be entered in the following format: MM/DD/YYYY. Failure to do so will result in an invalid form.
AED Present:
*
Yes
No
Battery OK:
*
Yes
No
Razor Present
*
Yes
No
Adult Pads Set 1: Present:
*
Yes
No
Date:
*
Expired?
*
Yes
No
Pediatric Pads Present:
*
Yes
No
Date:
*
Expired?
*
Yes
No
Glucometer Present/Functions:
*
Yes
No
Test Strips Present:
*
Yes
No
Date:
*
Expired?
*
Yes
No
Glucose Tube 1:
*
Yes
No
Date:
*
Expired?
*
Yes
No
Glucose Tube 2:
*
Yes
No
Date:
*
Expired?
*
Yes
No
Adult EPI Present:
*
Yes
No
Date:
*
Expired?
*
Yes
No
Pediatric EPI Present:
*
Yes
No
Date:
*
Expired?
*
Yes
No
Sterile Water Present:
*
Yes
No
Date:
*
Expired?
*
Yes
No
Aspirin:
*
Yes
No
Expired?
*
Yes
No
Date:
*
O2 PSI:
*
Spare O2:
*
Yes
No
Adult BVM:
*
Yes
No
Ped BVM:
*
Yes
No
6 Oral Airways:
*
Yes
No
6 Nasal Airways:
*
Yes
No
Nasal in Date:
*
Yes
No
Surgical Lube:
*
Yes
No
Lube in Date:
*
Yes
No
Naloxone Present?
*
Yes
No
Naloxone #1 Expiration Date
*
Naloxone #2 Expiration Date
*
Nasal Atomizer Present?
*
Yes
No
Stop the Bleed Kit Present?
*
Yes
No
Stop the Bleed Kit Sealed?
*
Yes
No
Bandaids Present with Stop the Bleed kit?
*
Yes
ADelosier@hagerstownmd.org
Notes/Remarks:
* indicates required fields.
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