1st of the Month Check-Off

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.