1st of the Month Check-Off 1st of the Month Check-Off 1st of the Month Check-Off First Name * (First Name) Last Name * Last Name Shift Location * Beaumont Baytown San Antonio The Woodlands Cypress/Katy Houston Corpus Christi Clear Lake/ Webster Kingwood Dallas Kingwood Longview College Station Round Rock New Braunfels Time Date Unit Number * M-101 M-102 M-103 M-104 M-105 M-106 M-107 M-108 M-109 M-110 M-111 M-112 M-113 M-114 M-115 M-116 M-117 M-118 M-119 M-120 Vehicle Number * M-101 M-102 M-103 M-104 M-105 M-106 M-107 M-108 M-109 M-110 M-111 M-112 M-113 M-114 M-115 M-116 M-117 M-118 M-119 M-120 Last 4 of VIN * Adenosine 12mg/4ml OR 6mg/2ml (6 Required) #REQ # ON UNIT - Adenosine * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 EXP. DATE 17 EXP. DATE 18 EXP. DATE 19 EXP. DATE 20 EXP. DATE 21 EXP. DATE 22 EXP. DATE 23 EXP. DATE 24 EXP. DATE 25 Notes Albuterol Sulfate UNIT DOSE 2.5mg/3ml (4 Required) #REQ # ON UNIT - Albuterol * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 EXP. DATE 17 EXP. DATE 18 EXP. DATE 19 EXP. DATE 20 EXP. DATE 21 EXP. DATE 22 EXP. DATE 23 EXP. DATE 24 EXP. DATE 25 Notes Amiodarone 150mg/3ml (3 Required) #REQ # ON UNIT - Amiodarone * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 EXP. DATE 17 EXP. DATE 18 EXP. DATE 19 EXP. DATE 20 EXP. DATE 21 EXP. DATE 22 EXP. DATE 23 EXP. DATE 24 EXP. DATE 25 Notes Anaphylaxis Kit #REQ # ON UNIT - Anaphylaxis Kit * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 EXP. DATE 17 EXP. DATE 18 EXP. DATE 19 EXP. DATE 20 Notes Asprin 81mg (1 Required) #REQ # ON UNIT - Asprin * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 Notes Atropine Sulfate 1mg/10ml (3 Required) #REQ # ON UNIT - Atropine Sulfate * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 Notes Benadryl (3 Required) #REQ # ON UNIT - Benadryl * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 Notes Dexamethasone 10mg/ml (3 Required) #REQ # ON UNIT - Dexamethasone * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 Notes Dextrose 50% 25g/50ml (3 Required) #REQ # ON UNIT - Dextrose * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 Notes Dopamine 400mg 1600 mcg/ml (premix )in D5W (1 Required) #REQ # ON UNIT - Dopamine * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 Notes Epinepherine 1:1000 1mg/ml (2 Required) #REQ # ON UNIT - Epinepherine 1:1000 * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 Notes Epinepherine 1:10,000 1mg/10ml (2 Required) #REQ # ON UNIT - Epinepherine 1:10,000 * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 Notes Magnesium Sulfate 5mg/10ml (2 Required) #REQ # ON UNIT - Magnesium Sulfate * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 EXP. DATE 17 EXP. DATE 18 EXP. DATE 19 EXP. DATE 20 EXP. DATE 21 EXP. DATE 22 EXP. DATE 23 EXP. DATE 24 EXP. DATE 25 Notes Naloxone (Narcan) 2mg/2ml (2 Required) #REQ # ON UNIT - Naloxone (Narcan) * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 Notes Nitroglycerin (Nitrostat) 400mcq PER SPRAY OR TABLETS 0.4MG (1 Required) #REQ # ON UNIT - Nitroglycerin (Nitrostat) * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 Notes Ondansetron (Zofran) 4mg/2ml (2 Required) #REQ # ON UNIT - Ondansetron (Zofran) * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 Notes Oral Glucose 15g PER TUBE (2 Required) #REQ # ON UNIT - Oral Glucose 15g PER TUBE * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 Notes Sodium Bicarbonate 50meq 1meq/ml (2 Required) #REQ # ON UNIT - Sodium Bicarbonate * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 Notes Versed 2mg/2ml (2 Required) #REQ # ON UNIT - Versed 2mg/2ml * EXP. DATE 1 * EXP. DATE 2 EXP. DATE 3 EXP. DATE 4 EXP. DATE 5 EXP. DATE 6 EXP. DATE 7 EXP. DATE 8 EXP. DATE 9 EXP. DATE 10 EXP. DATE 11 EXP. DATE 12 EXP. DATE 13 EXP. DATE 14 EXP. DATE 15 EXP. DATE 16 EXP. DATE 17 EXP. DATE 18 EXP. DATE 19 EXP. DATE 20 EXP. DATE 21 EXP. DATE 22 EXP. DATE 23 EXP. DATE 24 EXP. DATE 25 Notes Signature * Clear Please sign using a stylus or finger on any touch screen device. reCAPTCHA Text If you are human, leave this field blank.