Please enable JavaScript in your browser to complete this form.Date / TimeDateTimeChecked off by (all that assisted): *Steve ShelorWayne AkersBecky ShelorMike HaubnerLee WatsonRick LearyJennifer BarnettAmber SheppardAnnalyse BedwellAshley LewisBreana AkersChris ShelorChristian VanceJames AllbeeZoll MonitorZoll Daily / Shift Check Procedure (Check as you do each step): *Ensure that the X Series unit is clean (with no fluid spills) and free of visible damage.Inspect all cables, cords, and connectors for signs of damage or excessive wear (cuts in insulation, fraying, broken wires, dirty or bent connector pins). Replace if damaged.Inspect the battery, ECG patient cable, multifunction cable (MFC), OneStep cable, pulse oximetry sensor, blood pressure cuff, and hose and temperature sensors for signs of damage or excessive wear. Replace if damaged.Inspect the external AC adapter and its power cords for signs of damage. Replace if damaged.Check supply inventory (below) and add supplies as needed.Open the printer door on the left side unit and verify that an appropriate (> 1/2 roll) of paper is installed in the unit. Change if needed.Verify that a charged battery is fully inserted into the battery compartment of the X Series unit.Ensure that a fully charged spare battery pack is available.Check the Ready For Use (RFU) indicator on the X Series front panel. Verify that the RFU symbol is displayed.If the READY-FOR-USE (RFU) indicator is flashing or displaying the Do Not Use symbol, then either an equipment fault has been detected or the unit's battery is low or not properly installed. Install a fully charged battery in the unit and check the RFU indicator again. If the RFU indicator continues to flash or display the Do Not Use symbol, remove the unit from service and contact the appropriate technical personnel or the ZOLL Technical Service Department.Zoll Supplies ECG Patches Left Side, Open Pouch (2 Packs)ECG Patches (Packs) *ECG Patch Expiration *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Adult Defib / Pacing Pad Right Side Pouch, Minimum 1Adult Statpadz Qty *Adult Statpadz Expire *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Pediatric Defib / Pacing Pad Right Side Pouch, Minimum 1Ped StatPadz Qty *Ped StatPadz Expire: *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Front Wall (Upper)General SuppliesDisinfectant WipesPaper Towels (>1/2 Roll)Nitrile Gloves (XL) (> 1/2 Box)Glove Cabinet Above Side Door *Nitrile Gloves (S) (> 1/2 Box)Nitrile Gloves (M) (> 1/2 Box)Nitrile Gloves (L) (> 1/2 Box)Dell Laptop *Damaged?Charging?Keyboard Cover?Verizon Hotspot (Plugged in and On)Portable SuctionPortable Suction Unit *Unit plugged in and charging?New container?Suction tubing & catheter?Unplug portable suction and run for 15 seconds.Working properlyNot working properlyEZ-IO Kit (Yellow Bag)Supplies *IO DriverAlcohol Preps (5)Instruction Card10 ml Normal Saline Flush (Min 1)NS Flush QtyNS Flush Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Extension Sets (Min 1)Extension Set QtyExtension Set Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025IO Needle plus Stabilizer (Min 1) Pink 15 mm x 1.8 15 GaugePink Set QtyPink Set Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025IO Needle plus Stabilizer (Min 1) Blue 25 mm x 1.8 15 GaugeBlue Set QtyBlue Set Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025IO Needle plus Stabilizer (Min 1) Yellow 45 mm x 1.8 15 GaugeYellow Set QtyYellow Set Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Fire Extinguisher Confirm the extinguisher is visible, unobstructed, and in its designated location. Verify the locking pin is intact and the tamper seal is unbroken. Examine the extinguisher for obvious physical damage, corrosion, leakage, or clogged nozzle. Confirm the pressure gauge or indicator is in the operable range or position. Lift the extinguisher to ensure it is still full. Invert/shake to ensure contents aren't caked. Make sure the operating instructions on the nameplate are legible and facing outward. Check the last professional service date on the tag. Initial and date the back of the tag. Use MO/YR on date. Fire Extinguisher *Pin in placeSeal intactGauge is greenYearly in dateInitialed /Dated TagMiscellaneousSafety Vests (2 Minimum)Mass Casualty Triage Kits (2)Triage Tags (1 Pack)Front Wall Tray: MiscellaneousMiscellaneous / BatteriesAA Batteries (4)AAA Batteries (4)Penlights (2)Broselow TapeContact Lens CaseVein LightMag LightDrug CabinetDrug Box Number *Drug Box Seal Number *Drug Box Expiration *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Drug Box CommentsAncillary Drugs Narcan (Naloxone) Nasal Spray, 4mg Minimum 1 Box of 2 DosesNarcan QuantityNarcan ExpirationMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025EpiPen (Epinephrine) Adult, .3mg unit dose YELLOW, Minimum One DoseAdult (Yellow) EpiPen QtyAdult (Yellow) EpiPen Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025EpiPen (Epinephrine) Pediatric, .15mg unit dose GREEN, Minimum One DosePeds (Green) EpiPen QtyPeds (Green) EpiPen Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Compartment AENDOTRACHEAL TUBES & SUPPLIES 1 Set 2.5mm - 10mm in Airway Roll 1 Set 2.5mm - 10mm in Cabinet 2.5 mm Uncuffed ET TubeETT 2.5 Qty *ETT 2.5 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420253.0 mm Uncuffed ET TubeETT 3.0 Qty *ETT 3.0 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420253.5 mm Uncuffed ET TubeETT 3.5 Qty *ETT 3.5 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420254.0 mm ET TubeETT 4.0 Qty *ETT 4.0 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420254.5 mm ET TubeETT 4.5 Qty *ETT 4.5 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420255.0 mm ET TubeETT 5.0 Qty *ETT 5.0 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420255.5 mm ET TubeETT 5.5 Qty *ETT 5.5 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420256.0 mm ET TubeETT 6.0 Qty *ETT 6.0 *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420256.5 mm ET TubeETT 6.5 Qty *ETT 6.5 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420257.0 mm ET TubeETT 7.0 Qty *ETT 7.0 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420257.5 mm ET TubeETT 7.5 Qty *ETT 7.5 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420258.0 mm ET TubeETT 8.0 Qty *ETT 8.0 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY201820192020202120222023202420259.0 mm ET TubeETT 9.0 Qty *ETT 9.0 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2018201920202021202220232024202510.0 mm ET TubeETT 10.0 Qty *ETT 10.0 Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Adult Bougies, Minimum (2)Bougies Qty *Bougies Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Adult Bougies, Minimum (2)Adult Stylette Qty *Adult Stylette Exp *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Cabinet 1 (Lower Shelf)Front SectionPocket Masks (2)Oropharyngeal (Oral) Airways50 mm (1)60 mm (1)70 mm (1)80 mm (1)90 mm (1)100 mm (1)Nasopharyngeal Airways(NPA)Nasopharyngeal Airway, 24 FR Minimum (1) RequiredNPA 24 QtyNPA 24 FR ExpMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Nasopharyngeal Airway, 26 FR Minimum (1) RequiredNPA 26 QtyNPA 26 FR ExpMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Nasopharyngeal Airway, 28 FR Minimum (1) RequiredNPA 28 QtyNPA 28 FR ExpMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Nasopharyngeal Airway, 30 FR Minimum (1) RequiredNPA 30 QtyNPA 30 FR ExpMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Lubricating Jelly Water-soluble Minimum (5) PacketsLubricating Jelly QtyLubricating Jelly ExpMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Rear SectionAdult ETCO2 Detector Minimum (2) RequiredAdult ETCO2 Det. QtyAdult ETCO2 Det. Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Pediatric ETCO2 Detector Minimum (2) RequiredPeds ETCO2 Det. QtyPeds ETCO2 Det. Exp.MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025ET Tube HoldersAdult ET Tube Holder (Min. 1)Pediatric ET Tube Holder (Min. 1)2" Wide Hy-Tape (Pink Tape)Yankauer Suction Catheters (with or without control vent) Minimum (2) RequiredYankauer Qty *Suction Catheter (6 FR) Minimum (2)6 FR Suction Qty *Suction Catheter (8 FR) Minimum (2)8 FR Suction Qty *Suction Catheter (10 FR) Minimum (2)10 FR Suction Qty *Suction Catheter (12 FR) Minimum (2)12 FR Suction Qty *Suction Catheter (14 FR) Minimum (2)14 FR Suction Qty *Suction Catheter (16 FR) Minimum (2)16 FR Suction Qty *Suction Catheter (18 FR) Minimum (2)18 FR Suction Qty *Lubricating Jelly Water Soluble Minimum 5 PacketsLube Jelly Pack Qty *Lube Jelly ExpiresMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20182019202020212022202320242025Tray 2: Nebulizers & HumidifiersNebulizer Kit Minimum (2)Nebulizer Kit Qty *Humidifier Kit Minimum (2)Humidifier Kit Qty (copy) *Tray 3: Adult CannulaeAdult Nasal Cannulae Minimum (2)Adult Nasal Cannula Qty *Tray 4: Adult Non-RebreathersAdult Non-Rebreathing Face Masks Minimum (2)Adult NRB Qty *Tray 5: Pediatric OxygenPediatric Nasal Cannula Minimum (2)Peds Nasal Cannula Qty *Pediatric Non-Rebreathing Face Masks Minimum (2)Peds NRB Qty *Tray 6: Infant OxygenInfant Nasal Cannula Minimum (2)Infant Nasal Cannula Qty *Infant High-Concentration Face Masks Minimum (2)Infant High-Conc Mask Qty *Cabinet 2Upper ShelfUpper ShelfCravats (12)Emergency Blankets (2)Bloodstopper Dressings (4)4" Roller Gauze (Min. 4)2" Roller Gauze (Min. 4)Other Assorted Roller Gauze (4)Convenience Bags (4)Emesis Basins (2)Infection Control Kits (4)Safety Glasses (2)Face Masks (4)Face Masks w/ Shields (4)Lower Shelf HALO Chest Seals Halo QTYHALO EXPLSMFR Chest Decompression Kit (Ziploc Bag Back of Cabinet) Note 1st expiring item.Decomp Kit QTYDecomp Kit EXPTray 1 *Alcohol Preps (12)Fingernail Polish Removers (6)Povidone - Iodine Wipes (12)Bandaids (1" x 3") (12)Antibiotic Ointment (12)Nose Aids (2)Tray 2 *Ammonia Inhalants (6)Sting-Ease Swabs (6)Z-Fold Gauze Dressings (2)Tray 3 *4x4's (48)2x2's (24)Band Aids (24)Trauma Shears (1)Tray 4 *1" Tape (4)2" or > Tape (4)Tray 5 *Toruniquets (2)2" Elastic Bandage (2)4" Elastic Bandage (2)Cabinet 3Protocol ManualsNew (2019) ProtocolsPrev (2016-2019) ProtocolsAdult Bag-Valve-Mask *AIRWAY ROLL Magill ForcepsLargeSmallLarge Laryngoscope HandleBatteries CheckedReady for UseLaryngoscope Blades * Ready for UseBulb Checked Miller 0Miller 0 Ready for UseMiller 0 Bulb CheckedMiller 1Miller 1 Ready for UseMiller 1 Bulb CheckedMiller 2Miller 2 Ready for UseMiller 2 Bulb CheckedMiller 3Miller 3 Ready for UseMiller 3 Bulb CheckedMac 3Mac 3 Ready for UseMac 3 Bulb CheckedMac 4Mac 4 Ready for UseMac 4 Bulb CheckedWisconsin 2Wisconsin 2 Ready for UseWisconsin 2 Bulb Checked 2.5 MM ETT QTY *2.5 MM ETT EXP *3.0 mm Uncuffed ET Tube3.0 MM ETT QTY *3.0 MM ETT EXP *3.5 mm Uncuffed ET Tube3.5 MM ETT QTY *3.5 MM ETT EXP *4.0 mm ET Tube4.0 MM ETT QTY *4.0 MM ETT EXP *4.5 mm ET Tube4.5 MM ETT QTY *4.5 MM ETT EXP *5.0 mm ET Tube5.0 MM ETT QTY *5.0 MM ETT EXP *5.5 mm ET Tube5.5 MM ETT QTY *5.5 MM ETT EXP *6.0 mm ET Tube6.0 MM ETT QTY *6.0 MM ETT EXP *6.5 mm ET Tube6.5 MM ETT QTY *6.5 MM ETT EXP *7.0 mm ET Tube7.0 MM ETT QTY *7.0 MM ETT EXP *7.5 mm ET Tube7.5 MM ETT QTY *7.5 MM ETT EXP *8.0 mm ET Tube8.0 MM ETT QTY *8.0 MM ETT EXP *9.0 mm ET Tube9.0 MM ETT QTY *9.0 MM ETT EXP *10.0 mm ET Tube10.0 MM ETT QTY *10.0 MM ETT EXP *Adult Bougies, Minimum (2)Adult Bougie QTY *Adult Bougie EXP *Adult Stylettes, Minimum (2)Adult Stylette QTY *Adult Stylette EXP *Lubricating Jelly, Minimum (5) PacksLube Jelly QTY *Lube Jelly EXP *Cabinet 4Infant Bag-Valve Mask Minimum (1)Infant BVM Qty *Child Bag-Valve Mask Minimum (1)Child BVM Qty *Adult CPAP Kit Minimum (1)Adult CPAP Kit QtyAdult CPAP Kit ExpiresCabinet 5StethoscopesAdult StethoscopePediatric StethoscopeBlood Pressure Cuff KitBulb / GaugeInfant CuffChild CuffAdult CuffLarge Adult CuffCabinet 6Obstetrical Kits Minimum (2), SealedNumbersInstant Hot Packs Minimum (3)Hot Pack QuantityInstant Cold Packs Minimum (3)Cold Pack QuantityTrauma Dressings 10" x 30" or larger, Minimum (4)Trauma Dressing QtyWaterJel Burn Kit Kit, Complete Minimum 1CheckboxesYesNoNormal Saline for Irrigation 500 ml or 1 L Sealed Containers Minimum 4 Liters TotalNS Qty *NS Expires *Cabinet 7LUCAS2 Chest Compression SystemPlease inspect/test the LUCAS2 as outlined:Remove from carrying caseDevice is clean and has no damage.Check the bellows and suction cup.Check patient straps and stabilizer strap.Power the unit ON and check battery.Verify the unit starts and runs without unusual sounds.Check 30:2 mode to be sure it alerts and pauses for ventilation.Check continuous mode - LED should blink every 12 strokes.Return to carrying case.Cabinet 8Linen CabinetIn addition to linens on stretcher:Towels (min. 2)Blankets (Min. 2)Pillows (Min. 2)Pillow Cases (Min. 2)Sheets (Min. 4)Sharps & Waste DrawersSharps and waste drawers are located under the streetside drawer stack and the curbside attendant seat.Curbside DrawerSharps container is < 1/2 fullWaste basket has new red biohazard bag.Check if trash / sharps changed out.Streetside DrawerSharps container is < 1/2 fullWaste basket has new red biohazard bag.Check if trash / sharps changed out.CommentsDate / TimeDateTimeSignatureClear SignatureNameSubmit