ENGINE / TRUCK GREEN BAG CHECK
Crew Name Completing
*
Station
*
Please Select
Station #1
Station #2
Station #3
Unit Number
*
Please Select
29-15
19-08
33-21
16-06
Main Compartment
Portable Oxygen Cylinder
*
Present and Above 300 psi
Deficiency Noted In Comments
Oxygen Cylinder Warning
Comments
Adult Non-Rebreather
*
Present
Deficiency Noted In Comments
Adult NRB Warning
Comments
Pediatric Non-Rebreather
*
Present
Deficiency Noted In Comments
Peds NRB Warning
Comments
Infant Non-Rebreather
*
Present
Deficiency Noted In Comments
Infant NRB Warning
Comments
Nasal Cannula
*
Present
Deficiency Noted In Comments
Nasal Cannula Warning
Comments
Manual Portable Suction Unit (2 Rigid Catheters)
*
Present
Deficiency Noted In Comments
Manual Portable Suction Warning
Comments
Oral Airways
*
Infant
Child
Adult
Deficiency Noted in Comments
Oral Airway Warning
Comments
PPE Kits or Bagged Gowns (2 In Green Bag, 2 in Red Bag)
*
Present
Deficiency Noted in Comments
PPE Kit Warning
Comments
Main Compartment - Nasopharyngeal Airways
12 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
12 fr. Nasal Airway Warning
Comments
14 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
14 fr. Nasal Airway Warning
Comments
16 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
16 fr. Nasal Airway Warning
Comments
18 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
18 fr. Nasal Airway Warning
Comments
20 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
20 fr. Nasal Airway Warning
Comments
22 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
22 fr. Nasal Airway Warning
Comments
24 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
24 fr. Nasal Airway Warning
Comments
26 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
26 fr. Nasal Airway Warning
Comments
28 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
28 fr. Nasal Airway Warning
Comments
30 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
30 fr. Nasal Airway Warning
Comments
32 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
32 fr. Nasal Airway Warning
Comments
34 fr. Nasal Airway
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
34 fr. Nasal Airway Warning
Comments
Front Compartment - Intubation Roll
Large ET Handle
*
Present
Deficiency Noted In Comments
Large ET Warning
Comments
Small ET Handle
*
Present
Deficiency Noted In Comments
Small ET Warning
Comments
#0 Miller Blade (Straight)
*
Present
Deficiency Noted In Comments
0 Miller Warning
Comments
#1 Miller Blade (Straight)
*
Present
Deficiency Noted In Comments
1 Miller Warning
Comments
#2 Miller Blade (Straight)
*
Present
Deficiency Noted In Comments
2 Miller Warning
Comments
#3 Miller Blade (Straight)
*
Present
Deficiency Noted In Comments
3 Miller Warning
Comments
#1 Macintosh Blade (Curved)
*
Present
Deficiency Noted In Comments
1 Mac Warning
Comments
#2 Macintosh Blade (Curved)
*
Present
Deficiency Noted In Comments
2 Mac Warning
Comments
#3 Macintosh Blade (Curved)
*
Present
Deficiency Noted In Comments
3 Mac Warning
Comments
Large Forceps
*
Present
Deficiency Noted In Comments
Large Forceps Warning
Comments
Small Forceps
*
Present
Deficiency Noted In Comments
Small Forceps Warning
Comments
Hemostat
*
Present
Deficiency Noted In Comments
Hemostat Warning
Comments
10cc Syringe
*
Present
Deficiency Noted In Comments
10cc Syringe Warning
Comments
ET Tube Holder
*
Present
Deficiency Noted In Comments
ET Tube Holder Warning
Comments
Meconium Aspirator
*
Present
Deficiency Noted In Comments
Meconium Warning
Comments
1" Tape (1)
*
Present
Deficiency Noted In Comments
1" Tape Warning
Comments
Surgilube (3)
*
Present
Deficiency Noted In Comments
Surgilube Warning
Comments
Adult Stylet
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
Adult Stylet Warning
Comments
Peds Stylet
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
Ped Stylet Warning
Comments
Needle Cric Kit
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
Needle Cric Warning
Comments
2.5 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
2.5 Tube Warning
Comments
3.0 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
3.0 Tube Warning
Comments
3.5 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
3.5 Tube Warning
Comments
4.0 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
4.0 Tube Warning
Comments
4.5 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
4.5 Tube Warning
Comments
5.0 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
5.0 Tube Warning
Comments
6.0 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
6.0 Tube Warning
Comments
6.5 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
6.5 Tube Warning
Comments
7.0 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
7.0 Tube Warning
Comments
7.5 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
7.5 Tube Warning
Comments
8.0 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
8.0 Tube Warning
Comments
9.0 ET Tube
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
9.0 Tube Warning
Comments
Rear Compartment
Adult BVM w/ Capnography
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
Adult BVM Warning
Comments
Peds BVM w/ Capnography and Infant Mask
*
Present and Not Expiring in the Next 6 Months
Deficiency Noted In Comments
Peds BVM Warning
Comments
Side Compartment
Pulse Oximeter
*
Present
Deficiency Noted In Comments
Pulse Ox Warning
Comments
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All Deficient Items Were Corrected?
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No (Explanation Required in Comments)
Comments
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