MCFRS EMS Equipment Defect Form

MCFRS EMS Equipment Defect Form

For Reporting Issues with: LifePak 15, LUCAS device, AED, Suction, Airtraq, CPAP, Sapphire IV Pump
(Only Check this box if you are getting a device/accessory from your EMS-DO)

This is an "After-Hours" submission
I need a(n) *
Example: Device = LP15; accessory = Chest Lead
Which accessory are you taking?

LP15 Therapy CableLP15 Chest LeadsLP15 Limb LeadsLP15 BP HoseLP15 M-LNCS AdapterLP15 Rainbow Probe (adult)LP15 Rainbow Probe (pediatric)LP15 BP Cuff (Lg Adult Long)LP15 BP Cuff (Lg Adult)LP15 BP Cuff (Adult)LP15 BP Cuff (Ped)LP15 BP Cuff (Infant)LP 15 BatteryLP1000 Battery (AED)Easy IO (with case)CPAP green o2 hoseCPAP o2 couplerCPAP o2 elbowLUCAS neck padLUCAS suction cupLUCAS batteryCot StrapsBlack Quik Litter
EMS Logistics will send a replacement to the EMS-DO to replenish their cage.
Which EMS-DO Cage are you borrowing from?*
Who is your EMS Duty Officer Today?*
Name*

FirstLast
Email*
Station #*
Unit Number*
Ex. PE701
Today's Date*

MonthDayYear
What device is being written up?*
Date Issue Began*

MonthDayYear
Serial Number:*
What accessories need replacement? Please provide a brief statement.*
Ex. LP 15 side pouches - zipper is broken. LP 15 Chest leads - Frayed
NEW Device Serial Number*
(Issued from After-Hours Cage)
** To locate LP15 serial number, remove battery #1 and it is right there.**
** Please order LP15 batteries from the EMS Supply Order Form**
** Serial Number for LUCAS device is located on one of the legs at the bottom.**
**AED Serial number is located on the bottom of the AED. Some AED's will need the bottom case removed.**
**Suction serial number is located on the bottom of the suction unit.**
**Sapphire IV Pump serial number is located on the back of the unit.**
**To find Airtraq Camera serial number: Power on the device, go to "menu", then "settings" then it will show "serial number" on the 6th line down.
**To find CPAP serial number, look on the back of the unit. It starts with 343.**
My device is:*

MalfunctioningDamagedMissing
Police Report Number:
RMAP Number:
Note: If you don't have RMAP or police report numbers, please Email them to MCFRS.EMSSupplies ASAP once you get them. Thanks!
Please describe the issue(s):*
Was there Patient involvement?*

YesNo
Please provide a statement about what happened:*
The following questions are for the FDA Medwatch form.

Please answer them to the best of your ability.
Did this failure/malfunction effect patient outcome?*

YesNo
How did this have an effect on the patient's outcome?*
Patient's initials:*
Or other form of identification. NOT name, medical records or SSN/
Patients DOB or age:*
Patient's ethnicity/race:*
Patient's gender:*
Patient's weight:*
Patient's Relevant Medical History:*
If none, type "None"
EMS Logistics will send a replacement to the EMS-DO to replenish their cage.
This is a short term LIFEPAK loaner and it is my responsibility to ensure pass-on to the oncoming shift that they will need to come to EMS logistics on the next business day to obtain a long term loaner. They will then return the short-term loaner to the after-hours cage.

I acknowledge
Please provide as much information as possible, to include Make/Model, serial numbers etc, as well as what the issue is.*
Please report to EMS Logistics to swap this device out M-F 0700-1300.

These devices should NOT be sent via courier due to their value.

Feel free to call (240) 777-2220 or (240) 243-7891 (sonim) to see if there is a light duty person available to deliver it.

After hours? Please contact your EMS duty officer and they can help you with a loaner from their after-hours cage.
Serial Number of replacement unit:
(If unit was replaced)
Disposition of repair:
Admin Use Only:
Should be Empty: