GS1 -Medical Gas Exchange Record

1

INFORMATION

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

2

Date of exchange* This field is required.

Date

3

E/CFR* This field is required.

First Name

Last Name

4

Pin* This field is required.

5

Call sign prefix* This field is required.

FR

ER

CR

SR

6

Call sign* This field is required.Digits only

7

Call Sign

8

Area* This field is required.

9

CFR Team name:* This field is required.

10

E-mail* This field is required.

11

GasesAre you

ReplacingReturning only

12

Gas replaced

Oxygen

13

Gas replaced 2

Entonox

14

Click here for example of where to find batch number

15

O2 Returned Serial/Batch* This field is required.

16

O2 Collected Serial/Batch* This field is required.

17

More than two O2 cylinders left in depot?

Yes

No

18

Entenox Returned Serial/Batch* This field is required.

19

Entenox Collected Serial/Batch* This field is required.

20

More than two Entenox cylinders left in depot?

Yes

No

21

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

yes

Swapped by Ambulance Crew

22

Where* This field is required.

Cheshire/Merseyside

Greater Manchester

Cumbria/Lancs

23

Which station in C&M* This field is required.

24

Which station in GM* This field is required.

25

Which station in C&L* This field is required.

26

Any relevant comment(optional)