EMS EQUIPMENT REQUEST FORM

THIS REQUEST MUST BE SUBMITTED TO SIMON MILLER   E-mail to millerja@gtc.edu 1-WEEK PRIOR TO START OF CLASS

Name of Class ______________________________ Lead Instructor _______________________________________

Course# ___________________________ Class Date_________________________ Start Time ________________

Location ______________________________________ Address _________________________________________

Building/room # ________________________ Contact person for equip. Drop-off ______________________________

Contact Telephone # ___________________________________ Date of Equipment Return________________________

Do you need Equipment to be picked up when you are finished with it? ___Yes ___ No

 

Airway Bag: # _____

Dressing Boxes: # _____

Assisted Meds:

*Indicate # of Bags you need

*Indicate # of Boxes you need

*Please indicate quantity

Contents of Bag Include:

Contents of Box Include:

 

3 - Airways - Nasal

10 - 2x2

____ EPI-pens Adult

5 - Airways - Oral

10 - 4x4

____ EPI-pens Jr.

1 - Adult Bag Valve Mask

4 - 5x9

____ Inhalers

1 - Laryngoscope

3 - 2" Kling

____ Nebulizers

1 - Large Blade

3 - 4" Kling

____ Accu-Cheks

1 - Small Blade

3 - 6" Kling

 

1 - McGill Forceps - Large

6 - Trauma Dressing

Splinting Equipment:

1 - McGill Forceps - Small

3 - Paper Cups

___ Air Splints

1 - Sponge - foreign airway

1 - Saran Wrap

___ Board Splints

1 - Cannula

12 - Triangular Bandages

___ Cervical Collars

1 - Non-rebreather mask

1 - Blanket

___ CID - Bashaw

1 - Simple Mask

1 - Pillow

___ CID - Ferno

1 - Oxygen tank with regulator

6 - Safety Pins

___ KED

1 - Oxygen tubing

1- Arm Splint

___ Long Boards

1 - Pocket mask - Laeradal

 

___ Long Board Straps 9ft

1 - Suction Catheter - French

Assessment Boxes: # ______

___ Long Board Quick straps

1 - Suction Catheter - Rigid

*Indicate # of Boxes you need

___ Pediatric Long Board

1 - Combitube

Contents of Box Include:

___ PRO Splints

1 - Trauma Scissor

3 - B/P Cuffs

___ Scoop Stretcher

1 - Roll Tape

3 - Stethoscopes

___ Spider Straps

1 - Blood Pressure Cuff

3 - Assorted Collars

___ Hare Traction Splint

1 - Stethoscope - Single

3 - Blankets

___ MAST - Adult

1 - Stethoscope - Double

 

___ MAST - Pediatric

1 - Bulb syringe

 

 

1 - Penlight

 

 

1 - Can lubrication - Pam

 

 

6 - Alcohol Wipes

 

 

 

 

Medic First Aid: choose ____Police or ____ Citizen

___ Scenario Binder/Videos/Class Rosters/Pocket Mask/ Gloves/Wipes

___ Face Shields - 36 per

___ Blankets

___ Dressing Boxes

___ AED Trainers

___ Adult Manikins

Manikins:

IV and Injection Supplies:

Other:

*Please indicate quantity

*Please indicate quantity

 

___ CPR - Adult

___ 22 - Gauge needles

___

___ CPR - Child

___ 20 - Gauge needles

___

___ CPR - Infant

___ IV Solutions

___

___ AED Trainers

___ Macro Tubing

___

___ Ambu bag Ad/Ch/Inf

___ Needles for Syringes

___

___Intubation Head - Adult

___ Sharpes Container

___

___Intubation Head - Infant

___ Sub Q Syringe

___

___ Airway Head

___10cc - Syringe

 

___ Suction Unit/Tubing

___ 30cc - Syringe

Extra:

___ V-Vac Suction

___ Tourniquets

___

___ OB - Manikin

___ IV Starter Arms

___

___ OB - Kits

___ IV Arms

___

 

 

___

Advanced Airway:

Assisted Meds:

___

*Please indicate quantity

*Please indicate quantity

___

___ Combitube

___ Dextrose 50%

___

___ ET Tubes w/10cc Syringe

___ Epinephrine 1:1000

___

___ ET Stylet

___ Epi-pen

 

___ ET Placement Syringe

___ Glucagon

 

___ Lubrication - (Pam)

___ Narcan

 

 

___ Albuterol - 2.5mg

 

 

___ Nebulizer

 

 

___ Nitro

 

 

 

 

*For any questions regarding this form please contact Simon Miller at 767-5076