Central DuPage EMS System
25 North Winfield Road Ambulance Inspection Form
Winfield, IL 60190
DEPARTMENT NAMEUNIT I.D. #INSPECTION DATE VEHICLE LICENSE #
Level of Service: BLS / ALS
VEHICLE IDENTIFICATION #
Meets IDPH Requirements YES / NO
......
[ ] / CONTAMINATION BAG (2) / [ ] / DECONTAMINATION SOLUTION
[ ] / PROTOCOL BOOK / [ ] / AMMONIA INHALANT (optional)
[ ] / DISASTER TAGS (1 SMART tag pack) / [ ] / DISPOSABLE NEEDLE CONTAMINATION BOX
[ ] / PULSE OXIMETER (adult & peds) / [ ] / BLOOD GLUCOSE MONITOR KIT
[ ] / HOT PACKS (2) / [ ] / HEAD BEDS (4)
[ ] / COLD PACKS (2) / [ ] / COMMUNICATION DEVICE (CELL / MERCI)
MONITOR AND SUPPLIES /
IV TUBING, EQUIPMENT AND FLUIDS
[ ] / MONITOR / DEFIBRILLATOR / [ ] MINI-DRIP TUBING (4)[ ] / ELECTRODES (adult and peds) / [ ] REGULAR TUBING (4)
[ ] / SPARE ECG CABLES (2) / [ ] 14g ANGIOCATHETER (6)
[ ] / 2 Adult Defibrillation Pads or paddles with gel / [ ] 16g ANGIOCATHETER (6)
[ ] / 1 Peds Defibrillation Pads or paddles with gel / [ ] 18g ANGIOCATHETER (6)
[ ] / EXTRA ECG PAPER (2) / [ ] 20g ANGIOCATHETER (6)
[ ] / EXTRA MONITOR BATTERY / [ ] 22g ANGIOCATHETER (6)
[ ] / RAZOR (2) / [ ] 24g ANGIOCATHETER (6)
[ ] / IODINE WIPES (4) / [ ] IV START KIT (4)
[ ] INTRAOSSEOUS NEEDLES (2 Adult / 2Peds)
[ ] IV BAG 0.9%NaCl 1000 mL (6)
[ ] IV EXTENSION SET (4)
[ ] / PRESSURE INFUSER (1)
AIRWAY MANAGEMENT
[ ] / LARYNGOSCOPE HANDLES / 1 ADULT 1 PEDIATRIC
[ ] / ADULT BLADES / 2 Straight 2 Curved
[ ] /
PEDIATRIC BLADE
/2 Straight
[ ] / ET TUBES SIZES 3-9 (2) / [ ] / LUBRICATING JELLY (2)[ ] / MAGILL FORCEPS (1 large & 1 small) / [ ] / ET RESTRAINING DEVICE (2)
[ ] / 2 SPARE BATTERIES (per handle) / [ ] / STYLETS (1 ea adult & peds)
[ ] / SYRINGE (various sizes) / [ ] / BOUGIE (1)
[ ] / SCALPEL (2) / [ ] / POSI-TUBE (1)
[ ] / NEBULIZER (2 HHN & 1 in-line) / [ ] / KING LT (1 ea size 3,4,5)
[ ] / C-PAP (1) / [ ] / MUCOSAL ATOMIZER DEVICE (MAD) (2)
[ ] / CAPNOGRAPHY (easy cap or waveform) / [ ] / HEMOSTATS
[ ] / RESPIRTECH PRO VENTILATOR (optional) / [ ] / MECONIUM ASPIRATOR (2)
[ ] / AIR-TRAQ (optional)
*** CHECK EXPIRATION DATES – ANYTHING EXPIRED MUST BE REMOVED PRIOR TO INSPECTION ***
Central DuPage Emergency Medical Services System
25 North Winfield Road
Winfield, IL 60190
Total
/Total
[ ] / ADENOSINE exp ______30 mg TOTAL / [ ] 2 / FENTANYL exp ______
100 mcg
[ ] 2 / ALBUTEROL exp ______
2.5 mg / [ ] 2 / GLUCAGON exp ______
1 mg
[ ] 3 / AMIODARONE exp ______
150 MG / [ ] 3 / LIDOCAINE exp ______
100mg
[ ] 1 BOX / AMYL NITRATE exp ______
(optional) / [ ] 1 / MIDAZOLAM exp ______
10 mg total (IN/IM)
[ ] 8 / ASPIRIN exp ______
81 mg / [ ] 2 / MIDAZOLAM exp ______
5 mg (IVP/IO)
[ ] 2 / ATROPINE exp ______
1 mg 10mL preload / [ ] 4 / NARCAN exp ______
2 mg
[ ] 1 / TOPEX 20% SPRAY exp ______
(hurricane/benzocaine) / [ ] 2 / NITROGLYCERIN 0.4mg
bottle / spray exp ______
[ ] 2 / DEXTROSE 50% exp ______
(25 g/50mL) / [ ] 1 / ORAL GLOCOSE exp ______
(optional)
[ ] 2 / DEXTROSE 25% exp ______
(12.5 g) / [ ] 6 / SALINE FLUSHES exp ______
(0.9% NaCl)
[ ] 2 / DIPHENHYDRAMINE
50mg exp ______ / [ ] 4 / SALINE RESPIRATORY
(0.9% NaCl tubes) exp ______
[ ] 1 / DOPAMINE exp ______
800 mg/500 mL D5W / [ ] 2 / SODIUM BICARBONATE
44.6 mEq/50 mL exp ______
[ ] 5 / EPINEPHRINE exp ______
1:1,000 1mL (amp/vial) / [ ] 1 / TETRACAINE HCl
0.5% mL drops exp ______
[ ] 8 / EPINEPHRINE exp ______
1:10,000 1mg / [ ] 2 / ZOFRAN exp ______
4 mg ODT
[ ] 2 / ETOMIDATE exp ______
40 mg / [ ] 2 / ZOFRAN exp ______
4 mg vial / ampule
[ ] / NITROUS OXIDE
(optional) / [ ] 1 / DEXTROSE 5% / WATER
100ML IVPB
*** Please note the oldest expiration date for the medications listed ***
DEPARTMENT REPRESENTATIVESYSTEM REPRESENTATIVE
1
10/20/2015