GS1 -Medical Gas Exchange Record

1

INFORMATION

Please contact your respective NWAS CRT lead if there are 2 or less cylinders remaining post exchange

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2

Date of exchange* This field is required

Date

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3

E/CFR* This field is required

First Name

Last Name

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4

Pin* This field is required

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5

Call sign prefix* This field is required

FR

ER

CR

SR

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6

Call sign* This field is requiredDigits only

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7

Call Sign

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8

Area* This field is required

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9

CFR Team name:* This field is required

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10

E-mail* This field is required

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11

GasesAre you

ReplacingReturning only

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12

Gas replaced

Oxygen

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13

Gas replaced

Entonox

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14

Click here for example of where to find batch number

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15

O2 Returned Serial/Batch* This field is required

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16

O2 Collected Serial/Batch* This field is required

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17

More than two O2 cylinders left in depot?

Yes

No

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18

Entenox Returned Serial/Batch* This field is required

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19

Entenox Collected Serial/Batch* This field is required

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20

More than two Entenox cylinders left in depot?

Yes

No

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21

Did you pick up from/return to an NWAS Station?* This field is required

yes

Swapped by Ambulance Crew

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22

Where* This field is required

Cheshire/Merseyside

Greater Manchester

Cumbria/Lancs

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23

Which station in C&M* This field is required

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24

Which station in GM* This field is required

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25

Which station in C&L* This field is required

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26

Any relevant comment(optional)

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