DEPARTMENT OF HEALTH SERVICES
  COUNTY OF LOS ANGELES
           
 

 SUBJECT: LPC INVENTORY AND CHECKLIST FOR ITEMS DEPLOYED
REFERENCE NO. 1106.1  

  
 RELEASING LPC:         

 RECEIVING FACILITY:

Items
Quantity On Hand
(Alt+Click to Edit)
Number Checked Out
Adenosine Injection (6mg/vial)
Albuterol Inhaler (20mg/inhaler)
Albuterol Oral Inhalation Solution (2.5mg/3ml/dose)
Amiodarone Injection (50mg/ampule)
Atropine Injection (0.4mg/ml) 20ml multi-dose vial
Calcium Chloride 10% Injection (1gm/10ml) Pre-Filled Syringe
Cefazolin Injection (1gm/vial)
Cephalexin Tablet (500mg/tablet)
Ciprofloxacin Capsule (500mg/capsule)
Diphtheria-Tetanus (Td) Adsorbed Dose Injection (0.5ml/dose) - Adult
Diphtheria-Tetanus Toxoid (DT) Injection (0.5ml/dose) - Peds
Dextrose 50% Injection (50ml syringe)
Diphenhydramine Injection (50mg/ml vial)
Dopamine Injection (200mg/vial)
Doxycycline Capsules (100mg/tablet)
Epinephrine Injection 1:1,000 (1mg/ml/ampule)
Epinephrine Injection 1:1,000 30ml vial
Epinephrine Injection 1:10,000 (1mg/10ml) Pre-Filled Syringe
Glucagon Injection (1mg/vial)
Haloperidol Injection (5mg/vial)
Haloperidol Tablet (5mg/tablet)
Insulin Regular Injection (100units/ml - 10ml vial)
Lactated Ringers Solution Injection (1000ml/bag)
Lidocaine Injection 2% (10mg/ml) Pre-Filled Syringe
Lidocaine Injection 1% (20ml/vial)

EFFECTIVE: 10-15-06
REVISED: 10-01-20
SUPERSEDES: 07-01-19

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 SUBJECT: LPC INVENTORY AND CHECKLIST FOR ITEMS DEPLOYED

REFERENCE NO. 1106.1 
Items
Quantity On Hand
Number Checked Out
Magnesium Sulfate Injection (1gm/2ml)
Naloxone Injection (2mg/vial)
Nitroglycerin Tablets or Spray (0.4mg/tablet or spray - 100 doses)
Ondansetron Injection (2mg/vial)
Polymyxin Bacitracin Ointment (0.9gm/packet)
Potassium Chloride Injection (40mEQ/20ml)
Sodium Bicarbonate Injection (44.6mEQ/50 ml) Pre-Filled Syringe
Sodium Chloride 0.9% Injection (100ml/bag)
Sodium Chloride 0.9% Injection (1000ml/bag)
Sodium Polystyrene- Oral Powder (454gm/container)
Tetracaine Hydrochloride Ophthalmic Solution 0.5% (2ml/bottle) or
Proparacaine Hydrochloride Ophthalmic Solution 0.5% (15ml/bottle)
Other Supplies:  
Notes/Comments

Released by: 
Date released:
 
Received by: 
Facility:
 
Returned by:
Date returned:
 
Returned Items received by:
 
Statement of Verification

I hereby verify that an inventory of all Grant funded pharmaceuticals listed above has been completed and all items are up to PAR and available for deployment.

Verified By:    Date:
(Printed Name and Signature)

Should any item on the above list fall below PAR levels, notify the EMS Agency immediately.

Notification to EMS Agency by:     Date:

   
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