Equipment Log Form |

Date

Time*

: HH

MM

Unit is:*

Logging On
Logging Off
Performing Rig Exchange
Satellite Crew Exchange (Start of Shift)

Oncoming Crew #1*

First Last

Oncoming Crew #2

First Last

VST Completing Form*

Call Sign*

Fender Number*

Vehicle Mileage*

Gas Card Number*

Controlled Substance Box Number*

Please enter a number from 01 to 80.

List

Morphine Level	Versed Level

King Vision Present*

Yes
No

Rig Phone Number*

Sets of Keys*

Gurney Batteries Issued*

Monitor Batteries Issued*

Two
Three

Handheld Radio 1*

Handheld Radio 2*

Surface Tablet Issued*

Alpha Pager 1*

Alpha Pager 2

91 Pager 1*

91 Pager 2

Fire Radio*

Detail any Discrepancies

Acknowledgement*

By marking this box I acknowledge that the equipment recorded was present and accounted for at time of crew exchange. I will notify the supervisor immediately if any equipment was noted as missing.

Acknowledgement*

By marking this box I acknowledge that the equipment listed was issued to my unit.

Crew Member Receiving Equipment

First Last

To ensure that all PCRs have been completed download a trip reconciliation form from ImageTrend Elite Bridge and upload the results to this form. All PCRs (transports and cancellations) must be completed before the end of your shift.

Trip Reconciliation Upload

Upload your completed trip reconciliation obtained from ImageTrend Elite Bridge Report Writer. This will ensure that all PCRs have been posted and completed.

End of Shift

Check each box to ensure that all items have been accounted for according to company end of shift procedures:

Controlled Substances
Portable Radios
Ambulance Cell Phone
Alpha-Numeric Pagers
Frequency 91 Pagers
PCR Tablet
Ambulance Keys

Your Email for Receipt (Not Required)