Pharmacy Inspection Form

EMS Service:
Inspector Name:
Date of Inspection:

 

ALS SERVICE DRUG BOX


ALS Box# Vehicle#
Security Tag Number Is Box Secure?
1st Expiration Date: Medication Name:
Temperature Check
(Should be kept between 40/45 Farenheit)
Temp. Not Applicable

EPI & OVER the COUNTER MEDICATIONS


  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

Additional Information

By submitting this Inspection Form I verify that the identified drug box has been inspected per pharmacy control policies and procedures.
Submit an inspection form  for each vehicle Epi & OTC Meds are kept.
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Hope 4 Iowa

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Pottawattamie County Emergency Notification System

The Alert Iowa system serves all residents within Pottawattamie County and it's Communities.

The Pottawattamie County Emergency Management Agency has implemented The Alert Iowa system, a high-speed notification solution and Weather Warning service. This no-charge service is available to businesses.

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