Pottawattamie County - Departments ; Services - EMA: Pharmecy Inspection Form

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EMS Service
Inspector Name
Date of Inspection

ALS SERVICE DRUG BOX

Section Not Applicable
ALS Box#	Vehicle#
Security Tag Number	Is Box Secure?
1st Expiration Date: (Drugs expire last day of the month unless otherwise noted)	Medication Name:
Temperature Check Farenheit (Should be kept between 40/45 Farenheit)	Temp. Not Applicable

EPI & OVER the COUNTER MEDICATIONS

Applicable to ALL Services
	Vehicle#
(1) Adult Epi Auto-injector (0.3mg):	Expires
(1) Pediatric Epi Auto-injector (0.15mg):	Expires
Asprin (81mg chewables):	Quantity	1st Expiration
Oral Glucose:	Quantity	1st Expiration

By submitting this Inspection Form I verify that the identified drug box has been inspeccted per pharmacy control policies and procedures.
Submit an inspection form for each vehicle Epi & OTC Meds are kept.

Pharmacy Inspection Form