Narcotics Check-Off – Republic EMS

Narcotics Check Off

If you are human, leave this field blank.

Oncoming Medic / Paramedic #1 *

Patient Care Provider (First and Last Name REQUIRED!!!)

Driver/Operator Name *

Driver/Operator Name

Shift Location *

Unit Number *

Vehicle Number *

Time

Date

Versed (Count) *

Please insert the Versed count here. Versed is only to be stored in the narcotics lock box.

Relieved Medic / Paramedic #2 *

Who was the previous Paramedic on shift? Please Type their First and Last Name Above

Signature *

Please sign using a stylus or finger on any touch screen device.

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