Airway / IV (updated 04/05/15)
Crew name completing
*
Station #
*
Please Select
1
2
3
Vehicle number
*
Please Select
31-18
22-10
17-07
25-14
32-21
Old seal number #1
*
New seal number #1
*
Old seal number #2
*
New seal number #2
*
Date
-
Month
-
Day
Year
Date Picker Icon
"C" cell batteries
2 present
Amount needed (not replaced)
"AA" cell batteries
2 present
Amount needed (not replaced)
Small laryngoscope bulb
present
Large laryngoscope bulb
present
Pocket mask w/one way valve
present
Adult BVM (No Capnography)
present
Pediatric BVM (No Capnography)
present
Yankauer suction catheter (3)
present
Amount needed (not replaced)
Oxygen tubing (2)
present
Amount needed (not replaced)
Adult nasal cannula (3)
present
Amount needed (not replaced)
Pediatric nasal cannula (3)
present
Amount needed (not replaced)
Adult non-rebreather
present
Peds non-rebreather
present
Infant mask
present
6fr. suction catheter
2 present
amount needed (not replaced)
6fr expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
8fr. suction catheter
2present
amount needed (not replaced)
8fr expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
10fr. suction catheter
2 present
amount needed (not replaced)
10fr expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
12fr. suction catheter
2 present
amount needed (not replaced)
12fr expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
14fr. suction catheter
2 present
amount needed (not replaced)
14fr expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
16fr. suction catheter
2 present
amount needed (not replaced)
16fr expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
18fr. suction catheter
2 present
amount needed (not replaced)
18fr expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
2.5 E.T. tube
present
2.5ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
3.0 E.T. tube
present
3.0ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
3.5 E.T. tube
present
3.5ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
4.0 E.T. tube
present
4.0ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
4.5 E.T. tube
present
4.5ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
5.0 E.T. tube
present
5.0ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
6.0 E.T. tube
present
6.0ETexpiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
6.5 E.T. tube
present
6.5ETexpiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
7.0 E.T. tube
present
7.0ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
7.5 E.T. tube
present
7.5ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
8.0 E.T. tube
present
8.0ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
9.0 E.T. tube
present
9.0ET expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
40mm oral airway
present
50mm oral airway
present
60mm oral airway
present
70mm oral airway
present
80mm oral airway
present
90mm oral airway
present
100mm oral airway
present
110mm oral airway
present
IV Equipment
IV Start Kit (2)
present
IV Start Kit expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
.9 NS 1000cc (2)
present
.9 NS 1000cc (2) expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
Pressure Infuser
present
Pressure Infuser expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
Jamshidi Needle
present
Jamshidi Needle expiration date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2018
2017
2016
2015
2014
2013
Year
9" arm boards (2)
present
18" arm boards (2)
present
Notes
Submit
Should be Empty: