Zoll X Series Cardiac Monitor Check
Complete at least monthly
Date
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Month
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Day
Year
Date
Time
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Hour Minutes
Crew Member
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First Name
Last Name
EMS Certification Number
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Enter your six digit NYS certification number.
Cardiac Monitor #
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Darien Ambulance 45
Darien Squad 50
Both monitors checked with no problems identified. (If a problem is identified, please perform individual checks for each monitor and complete a check sheet for each).
Overall appearance of monitor is normal, and it is in good condition. Zippers all function normally and there is no visible damage or abnormality to monitor.
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Yes
No
Inventory & Expiration Dates
Please verify that the following items are present in the correct locations, correct quantity, and that they are not expired. Expired items should be replaced immediately and properly disposed of. If additional supplies need to be ordered, please inform an EMS officer. All locations are described with the monitor screen facing toward the inspector.
Left outside pocket contains: (1) Infant, (1) child, (1) regular adult, (1) large adult, (1) thigh blood pressure cuff, (1) Sp02 sensor.
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Yes
No
Left middle pocket contains: (1) 4 lead ECG cable, (1) 12 lead ECG cable, bag of >12 electrodes.
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Yes
No
Left inside pocket contains: All cables connected to the monitor and undamaged.
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Yes
No
Right inside pocket contains: (1) Adult ETC02 Oral/Nasal Sampling Set w/02 Tube, (1) Pediatric ETC02 Sampling Line and Airway Adapter, >2 Razor blades, (1) SP02 Pediatric cable. All cables are connected to the monitor and undamaged.
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Yes
No
Right outside pocket contains: (1) Zoll Adult AED Pads, (1) Zoll Pediatric AED Pads, (1) Zoll Defibrillation therapy cable, (1) Zoll Pad/CPR Adapter.
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Yes
No
Darien 45: Cabinet above the monitor contains (1) Spare roll of ECG paper, >12 spare electrodes, (2) 1ea. spare Adult/Pediatric AED pads. Darien Squad 50:
Yes
No
Additional Comments
Submit
Should be Empty: