Ambulance Red Bag Drugs Check
Crew Name Completing
*
Station
*
Please Select
Station #1
Station #2
Station #3
Unit Number
*
Please Select
25-14
17-07
22-10
31-18
32-21
Old Seal Number
*
New Seal Number
*
Atropine
Atropine (1mg/10ml) 1 Syringe
*
Present
Missing / Expired
Atro Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Atropine
Amount Needed (Not Replaced)
Please Select
1
AN Atropine
Baby Aspirin
Baby Aspirin (4 Pills)
*
Present
Missing / Expired
Aspirin Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Aspirin
Amount Needed (Not Replaced)
Please Select
1
2
AN Aspirin
Dextrose 50%
Dextrose 50% (25gm/50ml) 1 Syringe
*
Present
Missing / Expired
D50 Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED D50
Amount Needed (Not Replaced)
Please Select
1
AN D50
Epinephrine 1:10,000
Epinephrine 1:10,000 (1mg/10ml) 1 Syringe
*
Present
Missing / Expired
Epi 1:10 Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Epi 1:10
Amount Needed (Not Replaced)
Please Select
1
AN Epi 1:10
Ipratropium
Ipratropium Bromide (0.5mg/vial) 2 Vials
Present
Missing / Expired
Ipratropium Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
Ipratropium ED
Amount Needed (Not Replaced)
Please Select
1
2
AN Ipratropium
Oral Glucose
Glutose Paste (15gm) 1 Tube
*
Present
Missing / Expired
Glucose Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Glucose
Amount Needed (Not Replaced)
Please Select
1
AN Glucose
Mucosal Atomization Device
Mucosal Atomization Device
*
Present
Missing / Expired
MAD Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Mad
Amount Needed (Not Replaced)
Please Select
1
AN Mad
Naloxone
Naloxone (2mg/2ml) 2 Syringes
*
Present
Missing / Expired
Naloxone Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Naloxone
Amount Needed (Not Replaced)
Please Select
1
2
AN Naloxone
Nitroglycerin
Nitroglycerin (1 Bottle)
*
Present
Missing / Expired
Nitroglycerin Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Nitroglycerin
Amount Needed (Not Replaced)
Please Select
1
AN Nitroglycerin
Albuterol
Albuterol (2.5mg/3ml) 2 Vial
*
Present
Missing / Expired
Albuterol Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Albtuerol
Amount Needed (Not Replaced)
Please Select
1
2
AN Proventil
Zofran (IV)
Zofran (Ondansetron) (4mg/2mL) 1 Vial
*
Present
Missing / Expired
Zofran IV Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Zofran IV
Amount Needed (Not Replaced)
Please Select
1
AN Zofran IV
Zofran (Tab)
Zofran ODT (4mg) 1 Tab
*
Present
Missing / Expired
Zofran Missing
Expiration Date
*
-
Month
-
Day
Year
Date Picker Icon
ED Zofran
Amount Needed (Not Replaced)
Please Select
1
AN Zofran
3cc Syringe
3cc Syringe
*
Present
Missing
Syringe Warning
Amount Needed (Not Replaced)
Please Select
1
AN Syringe
Needle for Syringe
Needle for Syringe
*
Present
Missing
Needle Warning
Amount Needed (Not Replaced)
Please Select
1
AN Needle
All Deficient Items Were Corrected?
*
Yes
No (Explanation Required in Comments)
Comments
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Submit
Clear Form
Date/Time
-
Month
-
Day
Year
Date Picker Icon
Day of the Week
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