EQUIPMENT CHECKLIST - IEMSA



EQUIPMENT CHECKLIST

SERVICE: _________________________________________________ DATE: _____/______/19____

Completed by: _________________________________________________________________________

DEFIBRILLATOR: (circle one) Comments and/or deficiencies:

1. Battery charged: yes no NA

2. Self test OK yes no NA

3. Clean tape/rewound yes no NA

SUCTION UNIT:

1. Unit tested & working yes no NA

2. Battery charged yes no NA

3. Tubing clean/ready for use yes no NA

OXYGEN TANK(s):

1. Valve open-level checked:

(level in PSI) 1.________ 2. ________ 3. ________ 4. ________

2. Tank(s) below 500 PSI

filled of changed: yes no NA

3. Tanks ready for use yes no NA

JUMP KIT:

1. Checked of required

supplies & equipment: yes no NA

2. Supplies restocked yes no NA

3. Other storage areas yes no NA

OTHER:

1. ____________________________ yes no NA

2. ____________________________ yes no NA

3. ____________________________ yes no NA

4. ____________________________ yes no NA

5. ____________________________ yes no NA

6. ____________________________ yes no NA

7. ____________________________ yes no NA

8. ____________________________ yes no NA

NO: REQUIRES COMMENT - NA: NOT APPLICABLE

EQUIPMENT CHECKLIST

SERVICE: _______________________________________________ DATE: _____/______/19____

Vehicle(s): #____ #____ Completed by: _______________________________

DEFIBRILLATOR: (circle one) Comments (No requires comment):

# # 1. Battery charged: YES NO NA

# # 2. Defibrillator pads (& monitoring) YES NO NA

# # 3. Clean, tape/rewound, cables (& reserve) YES NO NA

SUCTION UNIT:

# # 1. Unit tested & working YES NO NA

# # 2. Tubing clean/ready for use YES NO NA

OXYGEN TANK(s):

# # 1. Valve open-level checked: (level in PSI) YES NO NA

tank(s) #1________ #2 ________ #3 ________ #4 ________

# # 2. Tank(s) below 500 PSI filled or changed: YES NO NA

JUMP KIT(s):

# # 1. Checked of required supplies & equipment: YES NO NA

# # 2. Supplies restocked YES NO NA

# # 3. Other storage areas YES NO NA

OTHER: (List other equipment or items to be checked

# # 1. ____________________________ YES NO NA

# # 2. ____________________________ YES NO NA

# # 3. ____________________________ YES NO NA

# # 4. ____________________________ YES NO NA

# # 5. ____________________________ YES NO NA

# # 6. ____________________________ YES NO NA

# # 7. ____________________________ YES NO NA

# # 8. ____________________________ YES NO NA

# # 9. ____________________________ YES NO NA

# # 10. ____________________________ YES NO NA

# # 11. ____________________________ YES NO NA

# # 12. ____________________________ YES NO NA

# # 13. ____________________________ YES NO NA

# # 14. ____________________________ YES NO NA

# # 15. ____________________________ YES NO NA

# # 16. ____________________________ YES NO NA

# # 17. ____________________________ YES NO NA

VEHICLE / EQUIPMENT CHECKLIST

SERVICE: _______________________________________________ DATE: _____/______/19____

Vehicle(s): #_____ #_____ Completed by: _______________________________

DEFIBRILLATOR: (circle one) Comments (No requires comment):

# # 1. Battery charged: YES NO NA

# # 2. Defibrillator pads (& monitoring) YES NO NA

# # 3. Clean, tape/rewound, cables (& reserve) YES NO NA

SUCTION UNIT:

# # 1. Unit tested & working YES NO NA

# # 2. Tubing clean/ready for use YES NO NA

OXYGEN TANK(s):

# # 1. Valve open-level checked: (level in PSI) YES NO NA

tank(s) #1________ #2 ________ #3 ________ #4 ________

# # 2. Tank(s) below 500 PSI filled or changed: YES NO NA

JUMP KIT(s):

# # 1. Checked of required supplies & equipment: YES NO NA

# # 2. Supplies restocked YES NO NA

# # 3. Other storage areas YES NO NA

OTHER: (List other equipment or items to be checked

# # 1. ____________________________ YES NO NA

# # 2. ____________________________ YES NO NA

# # 3. ____________________________ YES NO NA

# # 4. ____________________________ YES NO NA

# # 5. ____________________________ YES NO NA

# # 6. ____________________________ YES NO NA

# # 7. ____________________________ YES NO NA

VEHICLE(s)

# # 1. Fluid levels (gas, oil, window wash) YES NO NA

# # 2. Lights (head/ tail lights, emergency) YES NO NA

# # 3. Tires, belts, hoses, windshield wipers YES NO NA

# # 4. Cleanliness (inside & outside) YES NO NA

# # Date last serviced ____/____/_____ mileage: __________

# # Date last serviced ____/____/_____ mileage: __________

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