ALS Daily Equipment Checklist

Enter NER Forms Password*

Daily ALS Equipment Checklist
Date*
Crew Last Name*
Crew Last Name*
Truck #*
Unit*
Cab Area
Cab Area*

FailPass
Items Missing

Street GuidesToughbook w/charger(1) Portable Radios(2) ANSI Safety VestsZoll Tablet w/charger
Forward Passenger Exterior Cabinet
Is this area stocked completely?*
Items missing?

Broslow Bag w/tape (sealed)CPAP/Vent Bag (sealed)Ventilator w/chargerK9 Kit
Oxygen Bag
Is this area stocked completely?*
Items missing?

Tank w/regulatorO2 Wrench(2) Adult canula(2) Adult NRB(2) Pedi Canula(2) Pedi NRBNebulizer
O2 Tank PSI Remaining*
Portable Suction
Is this area stocked completely?*
Items missing?

Portable Unit w/chargerSuction Cath 6FrSuction Cath 8 FrYankhauer w/tubingSuction Cath 10 Fr(2) face/eye shield(2) Pair Gloves
C-spine Bag
Is this area stocked completely?*
Items missing?

(3) Pedi Collars(3) Occiput Pads(4) Adult Collars(2) Rolls 2" Tape(9) 9' Straps(2) Sets Headblocks
Cardiac Monitor
Is this area stocked completely?*
Perform Defib Test @ 30J*

FailPass
Items missing?

Wall ChargerSpare BatteryETCo2 Nasal CanulasECG/12 Lead CablesETCo2 ETT Adapter(2) RazorsECG Paper4 /6 ElectrodesPediatric SpO2 Disposable Probe
ALS First-In Bag
Is this area stocked completely?*
Items missing?

Adult BP CuffPedi BP CuffAdult BVMStethoscopeSharps ContainerOPA SetNPA SetGlucometer(10) Test Strips(5) Lancets(10) Band-aids(2) Tourniquets(5) 14g IV Cath(5) 16g IV Cath(5) 18g IV Cath(5) 20g IV Cath(5) 22g IV Cath(5) 24g IV Cath1" Plastic TapeTrauma Pad(2) 5x9 Pads(12) 4x4 Gauze(2) 4" KlingBurn Sheet(4) IV Lock Sets500 mL NaCl(10) Alcohol PrepsEZ-IO Gun (Do Not Test)(2) Adult IO Needles(2) Pedi IO Needles(2) IO Lock SetsPressure Infuser Bag(2) Face/Eye ShieldsPen Light(4) Tegederms(2) Pairs L Gloves(4) Saline FlushesTrauma Shears2" Cloth Tape(2) Decompression Needles
Intubation Roll
Is this area stocked completely?*
Items missing?

ET Laryngoscope Handle(2) Tube HoldersYankhauer w/tubingMac 3 BladeMagill ForcepsMac 4 Blade(2) Surg Lube1" Plastic TapeMiller 3 BladeET Tube Size 6ET Tube Size 6.5Miller 4 BladeET Tube Size 7ET Tube Size 7.5(2) 10cc SyringesET Tube Size 8ET Tube Size 8.5Adult StyletteET Tube Size 9ETCo2 Colormetric Device
Bench Seat
Is this area stocked completely?*
Items missing?

(2) 15" Padded Board Splint(2) 3' Padded Board Splint(2) 4' Padded Board SplintTransfer SheetUrinal(2) Waterproof PillowsBedpanPedi-Mate
Stretcher/Interior
Is this area stocked completely?*
Items missing?

Cot w/restraints & IV PoleInhouse suction unit w/canister(2) O2 Regulators(2) Emesis BagsHand Cleanser
Rear Glove Cabinet
Is this area stocked completely?*
Items missing?

Box Small GlovesThigh BP CuffBox Med GlovesAdult BP CuffBox Lg GlovesPedi BP CuffBox XL Gloves(2) Box TissueInfant BP CuffDouble Bell Stethoscope
Rear Upper Cabinet
Is this area stocked completely?*
Items missing?

(4) Trauma DressingsBLS Trauma -foil, burn sheet, BSI kitsSterile OB Kit(2) Sets Soft RestraintsDisinfectant WipesBiozide Spray
Rear IV Cabinet
Is this area stocked completely?*
Items missing?

(5) 1L NaCL(4) Macro Dripsets(2) 500mL NaCL(4) Micro Dripsets(2) 250mL NaCL(2) Buretrol SetsPressure IV Infuser
Working Cabinet
Is this area stocked completely?*
Items missing?

Chest Decomp KitNeedles 5ea 18,21,23,24gButterfly 2ea 23,25gSyringes 3ea 1,3,10cc(3) 30mL SyringesSpare Sharps Box(5) 14g IV Caths(5) 16g IV Caths(10) 18g IV Caths(10) 20g IV Caths(5) 22g IV Caths(5) 24g IV Caths(5) IV Locks(10) Saline Flushes(12) 4x4 Gauze(10) Tourniquets(25) Alcohol Preps(2) Arm Boards(30) Lancets(10) TegadermsBox Glucometer Strips(4) Rolls 1" Tape(8) Triangle Bandages(8) 5x9 Pads(2) Cold Packs(2) Drinking Cups(2) Emesis BagsTrauma ShearsPen LightRing CutterBlood Draw Kit(2) Morgan Lense
Linen Cabinet/Chair Rack
Is this area stocked completely?*
Items missing?

(8) Sheets(4) Blankets(4) TowelsStairchair w/strapsShort Backboard(4) Pillow Cases
Tech Seat Airway/Monitor Cabinet
Is this area stocked completely?*
Items missing?

Pedi ETT 2.0-5.0Adult ETT 5.5-90Mac Blades 1,2,3,4Miller Blades 1,2,3,4Stylette(2) Bougie Introducers(2) Tube RestraintsScope bulb/battery(2) ETCo2 Colormetric DevicesNG Tubes 2ea 5,8,10,14 Fr(2) Airtraq Optical LaryngoscopeiGel Airways 3,4,5
Suction Cabinet
Is this area stocked completely?*
Items missing?

Portable Suction Canister(3) 1L Sterile WaterInhouse Suction Canister(2) Yankhauer w/tubing(2) Yankhauer w/tubing
Oxygen Supplies Cabinet
Is this area stocked completely?*
Items missing?

(4) Adult Nasal Cannulas(1) Oxygen Humidifier Set(4) Adult NRB(4) Pedi Nasal Cannulas(4) Nebulizer Sets(4) Pedi NRB
Tech Seatback Shelving
Is this area stocked completely?*
Items missing?

Adult BVM w/maskPedi BVM w/maskInfant BVM w/maskAdult vent circuit(2) N-95 Mask (sm-med)Pedi vent circuit(2) N-95 Mask (med-large)Binoculars(2) Large Bio bags w/ties(2) face/eye shield(2) Small Bio bags w/ties
External Oxygen Compartment
Is this area stocked completely?*
Onboard Tank PSI*
Items missing?

Oxygen wrench2 D-size O2 tanks2 Wheel ChocksMonitor Tray for stretcher
Exterior Board Cabinet
Is this area stocked completely?*
Items missing?

(2) Long SpineboardsScoop Stretcher
Final
Name of Crewmember submitting checklist*
Equipment Inspection Result*

Unsatisfactory (Notify Dispatch Immediately)Satisfactory
Should be Empty:

Daily ALS Equipment Checklist

Cab Area

Forward Passenger Exterior Cabinet

Oxygen Bag

Portable Suction

C-spine Bag

Cardiac Monitor

ALS First-In Bag

Intubation Roll

Bench Seat

Stretcher/Interior

Rear Glove Cabinet

Rear Upper Cabinet

Rear IV Cabinet

Working Cabinet

Linen Cabinet/Chair Rack

Tech Seat Airway/Monitor Cabinet

Suction Cabinet

Oxygen Supplies Cabinet

Tech Seatback Shelving

External Oxygen Compartment

Exterior Board Cabinet

Final