DEPARTMENT OF HEALTH SERVICES
  COUNTY OF LOS ANGELES
           
 
  SUBJECT: LPC INVENTORY AND  CHECKLIST FOR ITEMS DEPLOYED
REFERENCE NO. 1106.1   

  RELEASING DRC: {var ReleaseingDRC}             
  
RECEIVING FACILITY: {var facility}
Item
Quantity On Hand
(or equivalent)
Number Checked Out
Adenosine Injection (6mg/vial)
{var Q1}
{var CO1}
Albuterol Inhaler (20mg/inhaler)
{var Q2}
{var CO2}
Albuterol Oral Inhalation Solution (2.5mg/3ml/dose)
{var Q3}
{var CO3}
Amiodarone Injection (50mg/ampule)
{var Q4}
{var CO4}
Atropine Injection (0.4mg/ml) 20ml multi-dose vial
{var Q5}
{var CO5}
Calcium Chloride 10% Injection (1gm/10ml) Pre-Filled Syringe
{var Q6}
{var CO6}
Cefazolin Injection (1gm/vial)
{var Q7}
{var CO7}
Cephalexin Tablet (500mg/tablet)
{var Q8}
{var CO8}
Ciprofloxacin Capsule (500mg/capsule)
{var Q9}
{var CO9}
Diphtheria-Tetanus (Td) Adsorbed Dose Injection (0.5ml/dose) - Adult
{var Q10}
{var CO10}
Diphtheria-Tetanus Toxoid (DT) Injection (0.5ml/dose) - Ped
{var Q11}
{var CO11}
Dextrose 50% Injection (50ml syringe)
{var Q12}
{var CO12}
Diphenhydramine Injection (50mg/ml vial)
{var Q13}
{var CO13}
Dopamine Injection (200mg/vial)
{var Q14}
{var CO14}
Doxycycline Capsules (100mg/tablet)
{var Q15}
{var CO15}
Epinephrine Injection 1:1,000 (1mg/ml/ampule)
{var Q16}
{var CO16}
Epinephrine Injection 1:1,000 30ml vial
{var Q17}
{var CO17}
Epinephrine Injection 1:10,000 (1mg/10ml) Pre-Filled Syringe
{var Q18}
{var CO18}
Glucagon Injection (1mg/vial)
{var Q19}
{var CO19}
Haloperidol Injection (5mg/vial)
{var Q20}
{var CO20}
Haloperidol Tablet (5mg/tablet)
{var Q21}
{var CO21}
Insulin Regular Injection (100units/ml - 10ml vial)
{var Q22}
{var CO22}
Lactated Ringers Solution Injection (1000ml/bag)
{var Q23}
{var CO23}
Lidocaine Injection 2% (10mg/ml) Pre-Filled Syringe
{var Q24}
{var CO24} 
Lidocaine Injection 1% (20ml/vial)
{var Q25}
{var CO25} 

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


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Express Sending Station: {var MsgSender}  

 SUBJECT: DRC EQUIPMENT CHECKLIST LIST
                   ITEMS DEPLOYED TO OTHER FACILITIES

REFERENCE NO. 11022.2 
Item
Quantity On Hand
(or equivalent)
Number Checked Out
Magnesium Sulfate Injection (1gm/2ml)
{var Q26}
{var CO26} 
Naloxone Injection (2mg/vial)
{var Q27}
{var CO27} 
Nitroglycerin Tablets or Spray (0.4mg/tablet or spray - 100 doses)
{var Q28}
{var CO28} 
Ondansetron Injection (2mg/vial)
{var Q29}
{var CO29} 
Polymyxin Bacitracin Ointment (0.9gm/packet)
{var Q30}
{var CO30} 
Potassium Chloride Injection (40mEQ/20ml)
{var Q31}
{var CO31} 
Sodium Bicarbonate Injection (44.6mEQ/50 ml) Pre-Filled Syringe
{var Q32}
{var CO32} 
Sodium Chloride 0.9% Injection (100ml/bag
{var Q33}
{var CO33} 
Sodium Chloride 0.9% Injection (1000ml/bag)
{var Q34}
{var CO34} 
Sodium Polystyrene- Oral Powder (454gm/container)
{var Q35}
{var CO35} 
Tetracaine Hydrochloride Ophthalmic Solution 0.5% (2ml/bottle) or
Proparacaine Hydrochloride Ophthalmic Solution 0.5% (15ml/bottle)
{var Q36}
{var CO36} 
{var Other1}
{var Q37}
{var CO37} 
{var Other2}
{var Q38}
{var CO38} 
{var Other3};
{var Q39}
{var CO39} 
{var Other4} 
{var Q40}
{var CO40} 
{var Other5} 
{var Q41}
{var CO41} 

 Notes/Comments

{var Other6}

Released by: 
{var Releasedby} Date released: {var DateReleased}
 
Received by: 
{var Receivedby} Facility: {var Facility2}
 
Returned by:
{var Returnedby} Date returned: {var DateReturned}
 
Returned Items received by: {var ReturnedReceived}
 
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: {var Verifiedby}    Date: {var VerifyDate}
(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: {var Notificationby}     Date: {var NotificationDate}

 

 

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Express Sending Station: {var MsgSender}