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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