G3 Checklist CIP

1
1 OF 2
MEDICAL EQUIPMENT SETS
1 DECEMBER 2001
DIVISION SURGEON
TASK Maintain Medical Equipment
Sets CONDITIONS Given the mission of
maintaining Medical Equipment Sets STANDARDS
IAW the below cited references 1.
REFERENCES a. AR 40-2, Army Medical
Treatment Facilities, General Administration
b. AR 40-61, Medical Logistics and Procedures
c. AR 190-50, Physical Security for
Storage of Controlled Medical Supplies d.
AR 710-2, Supply Policy Below The Wholesale Level
e. DA Pam 710-2, Using Unit Supply
System f. TB MED 1, Storage, Preservation,
Packaging, Maintenance and Surveillance of
Material Medical Activities g. SB 8-75
Series, AMEDD Supply Information h. SC
6545, IL Vol. 12 i. CTA 8-100, AMEDD,
Expendable/Durable Items DMSO Quality Control
Directives Authorized Stockage List 2. PURPOSE
To ensure that Medical Equipment Sets are being
maintained IAW the above regulations 3.
SPECIFIC QUESTIONS a. Are the above
references on hand, on order, or readily
available? b. Does the unit ensure
property accountability of Medical Equipment Sets
by conducting semi annual inventories? (Para
5-6a, AR 40-61) c. Does the unit have or
have on order, all components authorized for the
Medical Equipment Sets? d. Are the Medical
Equipment Sets maintained in a clean and
operational state? e. Are TMs available
for all medical equipment?
2
2 OF 2
MEDICAL EQUIPMENT SETS
1 DECEMBER 2001
DIVISION SURGEON
f. Is the unit maintaining the Medical
Equipment Sets in a temperature controlled
environment as much as possible? g. Is the
unit ensuring quality control of pharmaceuticals
by using a potency data file on DA Form 4998-R
for all pharmaceuticals? h. Is the unit
maintaining Quality Control Directives and
indicating the actions taken for each
directive? i. Are all surgical instruments
properly cleaned and stored? j. Are
expired medications being identified during semi
annual inspections, and being replaced?
NOTES ________________________________________
__________________ _______________________________
___________________________ ______________________
____________________________________ _____________
_____________________________________________ ____
__________________________________________________
____ _____________________________________________
_____________ ____________________________________
______________________ ___________________________
_______________________________ __________________
________________________________________ VERIFI
CATION x_______________ Unit POC Signature,
Name, Rank, Date x_______________ Inspector
s Signature, Name, Rank, Date
3
1 OF 2
MEDICAL RECORDS
1 DECEMBER 2001
DIVISION SURGEON
TASK Maintain Medical Records. CONDITIONS
Given the mission of establishing and maintaining
unit medical records STANDARDS IAW the below
cited references 1. REFERENCES a.
AR 40-2, Army Medical Treatment Facilities,
General Administration b. AR 40-4, Army
Medical Department Facilities/Activities c.
AR 40-15, Medical Warning tag and Emergency
Medical Identification d. AR 40-48, Non
physician Health Care Providers e. AR
40-66, Medical Record and Quality Assurance
Administration f. AR 40-68, Quality
Assurance Administration g. AR 40-501,
Standards of Medical Fitness h. AR 40-562,
Immunizations and Chemoprphylaxis i. HSC
Pam 40-7-21 j. USAREUR Suppl 1 to AR 40-4,
Army Medical Department Facilities and Activities
2. PURPOSE To ensure that medical
records are being maintained IAW all cited
regulations 3. SPECIFIC QUESTIONS a.
Are the above references on hand, on order, or
readily available? b. Is access to health
care records appropriately limited to protect
privacy? (Para 5-4, AR 40-66) c. Does the
medical facility follow proper disclosure
procedures for medical information? (Para 2-3, AR
40-66) d. Are medical forms filed
correctly in the HREC? (Para 5-9, AR 40-66)
e. Are health records filed using the terminal
digit filing system? (Para 5-9, AR 40-66)
f. Is a charge out system used to track records
removed from files? (Para 4-6, AR 40-66) g.
Are temporary HRECs initiated correctly and are
they replaced with a new record if used over 60
days? (Para 5-8, AR 40-66) h. Is a DA
label 162 affixed to the front of the medical
folder for persons with medication allergies?
(Para 5a and 5b, AR 40-15 / Para 5-6e, AR
40-66)
4
2 OF 2
MEDICAL RECORDS
1 DECEMBER 2001
DIVISION SURGEON
i. Are medical warning tags ordered using
DA Form 3365 for medical conditions requiring
them? (Para 6, AR 40-15) j. Is the
required patient identification on each record
document? (Para 3-2, AR 40-66) k. Is the
privacy act statement signed? (Para 1-6c, AR
40-2) l. Are enlisted personnel that are
seeing patients using the APC 21? (Para 20,
USAREUR Suppl 1 to AR 40-4) m. Is
documentation of APC 21 training and
certification on hand for all enlisted personnel
who are seeing patients? (Para 12, HSC Pam
40-7-21) NOTES ________________________
__________________________________ _______________
___________________________________________ ______
__________________________________________________
__ _______________________________________________
___________ ______________________________________
____________________ _____________________________
_____________________________ ____________________
______________________________________ ___________
_______________________________________________ __
__________________________________________________
______ VERIFICATION x_______________ Unit
POC Signature, Name, Rank, Date x_____________
__ Inspectors Signature, Name, Rank, Date

5
1 OF 2
WEIGHT CONTROL PROGRAM
1 DECEMBER 2001
DIVISION SURGEON
TASK Maintain Weight Control Program CONDITIONS
Given the mission of establishing and
maintaining a unit weight control
program STANDARD IAW the below cited
references 1. REFERENCES



a. AR 600-9, The Army
Weight Control Program.
2.
PURPOSE To assess the effectiveness of the
units Weight Control Program 3. SPECIFIC
QUESTIONS

a. Are the above references on
hand, on order, or readily available?

b. Are soldiers
being screened for height and weight during their
semi-annual APFT? (Para 20a, AR 600-9)
c. Does the commander monitor all members of
their command to ensure that they maintain proper
weight, body composition and personal appearance?
(Para 20b, AR 600-9) d. Are personnel
enrolled in the weight control program weighed in
monthly to measure soldiers progress, and data
kept on file? (Para 21, AR 600-9) e. Does the
Commander notify all soldiers, in writing, that
they are enrolled in the program? (Para 21e, AR
600-9) f. If a soldier who has not
made satisfactory progress in the Weight Control
Program after any two consecutive monthly
weigh-ins, are they referred to health care
personnel for evaluation or reevaluation? (Para
21e (2), AR 600-9) g. Are soldiers only
removed from the weight control program when they
achieve the body fat standard? (Para 21f, AR
600-9) h. Within 12 months after removal
from a weight control program, and a soldier is
determined to exceed the screening table weight
and body fat standard with no underlying or
associated disease, is the soldier being
processed for separation proceedings? (Para 21k,
AR 600-9)
6
2 OF 2
WEIGHT CONTROL PROGRAM
1 DECEMBER 2001
DIVISION SURGEON
i. After 12 months but within 36 months
removal from a weight control program, a soldier
is determined to exceed the screening table
weight and body fat standard with no underlying
or associated disease, is the soldier allowed
only 90 days to meet the standard? (Para 21k, AR
600-9) j. Are soldiers allowed to remain
on the weight control program after the initial 6
months period? (Para 21h, AR 600-9)

k. Does the commander provide programs to
educate and motivate soldiers to attain and
maintain weight and body fat standards? (Para
20, AR 600-9) l. Are soldiers being
flagged when entered into weight control program?
(Para 21, AR 600-9)
NOTES ________________
__________________________________________ _______
__________________________________________________
_ ________________________________________________
__________ _______________________________________
___________________ ______________________________
____________________________ _____________________
_____________________________________ ____________
______________________________________________ ___
__________________________________________________
_____ ____________________________________________
______________ VERIFICATION x_______________
Unit POC Signature, Name, Rank,
Date x_______________ Inspectors
Signature, Name, Rank, Date







7
1 OF 2
FIELD SANITATION PROGRAM
1 DECEMBER 2001
DIVISION SURGEON
TASK Maintain Field Sanitation
operations. CONDITIONS Given the mission of
establishing and maintaining a unit field
sanitation program STANDARDS IAW the below
cited references 1. REFERENCES a. AR
40-5, Preventive Medicine b. FM 21-10, Field
Hygiene and Sanitation c. FM 21-10-1, Unit
Field Sanitation Team d. TM 9-2320-267-14P,
Operators, Organizational, Direct Support, and
General Support Maintenance Manual. Including
Repair Parts and Special Tools List for Trailer.
Tank, Potable Water, 400 gallons, 1 1/2 Ton, 2
Wheel, M-149 e. TB MED 577, Occupational and
Environmental Health Sanitary Control and
Surveillance of Field Water Supplies 2.
PURPOSE To assess the effectiveness of the
units Field Sanitation Program 3. SPECIFIC
QUESTIONS a. Are the above references on
hand, on order, or readily available? b.
Are there at least three field sanitation team
members, to include one NCO appointed on unit
orders? (Para 14-3b(2)(a), AR 40-5) c.
Have field sanitation team members received
formal field sanitation team training and are
copies of the certificates maintained by the
unit? (Para 14-3b(2)(b), AR 40-5) d. Do
field sanitation team members have at least 1
year remaining in their unit? (Para 14-3b(2)(a),
AR 40-5) e. Are field sanitation team
members appointed from organic medical assets, if
organic to unit? (Para 14-3b(2)(b), AR 40-5)
f. Does the field sanitation team conduct
training within the unit on individual preventive
medicine measures against disease and injury?
(Para 14-3b(2), AR 40-5) g. Are the water
trailers (if authorized) supporting the unit
deployability? i.e., properly cleaned and
sanitized, and all fixtures in good working
order. (TB MED 577, FM 21-10, TM
9-2330-267-14P) h. Does the unit maintain
the field sanitation equipment IAW cited
regulations? (Para 14-3a(11), AR
40-5)
8
2 OF 2
FIELD SANITATION PROGRAM
1 DECEMBER 2001
DIVISION SURGEON
i. Are any expendable supplies past their
expiration date? (Table 14-1, AR 40-5) j.
Are copies of shelf-life extensions on hand?
k. Are field sanitation supplies properly
stored (separate storage of medical supplies,
pesticides, and water purification supplies)
based on toxicity and potential cross
contamination? l. Have water trailers
been inspected and certified by Division
Preventive Medicine semiannually? If uncertified,
are all parts on order to correct deficiencies?
m. Is the field sanitation team conducting
monthly water trailer inspections using DA Form
5457R, Potable Water Container Inspection
Checklist. NOTES __________________________
________________________________ _________________
_________________________________________ ________
__________________________________________________
_________________________________________________
_________ ________________________________________
__________________ _______________________________
___________________________ ______________________
____________________________________ _____________
_____________________________________________ ____
__________________________________________________
____ VERIFICATION x_______________ Unit
POC Signature, Name, Rank, Date x______________
_ Inspectors Signature, Name, Rank, Date

9
1 OF 2
COMBAT LIFESAVER PROGRAM
1 DECEMBER 2001
DIVISION SURGEON
TASK Maintain Combat Lifesaver
Program. CONDITIONS Given the mission of
establishing and maintaining a unit Combat
Lifesaver Training Program STANDARDS IAW the
below cited references 1. REFERENCES
a. AR 40-61, Medical Logistics Policies and
Procedures b. USAREUR Reg 350-1, USAREUR
Training Program c. 1AD Policy Letter 1-12,
Combat Lifesaver and Emergency Medical Technician
2. PURPOSE To assess the effectiveness
of the units Combat Lifesaver Training Program
3. SPECIFIC QUESTIONS a. Are the above
references on hand, on order, or readily
available? b. Does the unit have one
Combat Lifesaver per squad, crew, team, or every
ten soldiers? (Para 2b, 1AD Policy Letter 1-12)
c. Do the trained Combat Lifesavers receive
annual recertification? (Para 2e, 1AD Policy
Letter 1-12) d. Does the unit maintain
accountability of all Combat Lifesaver bags?
e. Does the unit maintain a current packing
list inside of each Combat Lifesaver bag?
f. Are the Combat Lifesaver bags stocked
according to the packing list? g. Are all
Combat Lifesaver bags (that are authorized) on
hand or properly requisitioned? h. Are all
Combat Lifesaver bags maintained in a temperature
controlled environment as much as possible? (i.e.
not left in vehicles or rooms without heat and or
air-conditioning) i. Are the expirable
items in the Combat lifesaver bags replaced
within 90 days of the expiration date? (Para
5-6a3b, AR 40-61)

10
2 OF 2
COMBAT LIFESAVER PROGRAM
1 DECEMBER 2001
DIVISION SURGEON
NOTES __________________________________________
________________ _________________________________
_________________________ ________________________
__________________________________ _______________
___________________________________________ ______
__________________________________________________
__ _______________________________________________
___________ ______________________________________
____________________ _____________________________
_____________________________ ____________________
______________________________________ VERIFICA
TION x_______________ Unit POC Signature,
Name, Rank, Date x_______________ Inspector
s Signature, Name, Rank, Date
11
1 OF 2
HEARING CONSERVATION PROGRAM
1 DECEMBER 2001
DIVISION SURGEON
TASK Maintain Hearing Conservation
Program CONDITIONS Given the mission of
establishing and maintaining a unit hearing
conservation program STANDARD IAW the below
cited references 1. REFERENCES



a. DA Pam
40-501, Hearing Conservation b. AR 40-5,
Preventive Medicine
2.
PURPOSE To assess the effectiveness of the
units Hearing Conservation Program 3.
SPECIFIC QUESTIONS a. Are the above
references on hand, on order, or readily
available? b. Does the unit have a
hearing conservation officer/NCO appointed on
unit orders to oversee the unit program? (Para
5-16b(9)(a), AR 40-5) c. Does the unit
maintain a local SOP detailing the hearing
conservation program? (Para 5-16b(9)(g)(2), AR
40-5) d. Do soldiers receive (at least
annually) training on the harmful effects of
noise and the proper use and care of hearing
protection devices? (Para 5-16b(9)(g)(2), AR
40-5) e. Do all soldiers working or
entering designated noise hazardous areas have
approved protection devices in their possession?
(Para 5-16b(9)(g)(2) f. Is the mandatory
use of hearing protection devices by all soldiers
entering or working in noise hazardous areas
enforced? (Para 5-16, AR 40-5) g. Is an
inventory of all noise hazardous operations and
equipment maintained? (Para 5-16(8)(c), AR 40-5)
h. Are approved pre-formed earplugs
fitted and issued to all soldiers? (Para 6-3a, DA
Pam 40-501) i. Are annual audiometric
evaluations performed for all soldiers by birth
month? j. Are hearing protection devices
(earplugs, and earmuffs) being maintained by the
unit? (Para 5-13, Para d1 and 9, AR 40-5)


12
2 OF 2
HEARING CONSERVATION PROGRAM
1 DECEMBER 2001
DIVISION SURGEON
k. Is noise hazardous equipment posted with
caution signs or decals? (Para 5-13, Para c-2, AR
40-5) l. Are caution signs posted at eye level
at the entrances to or periphery of noise
hazardous areas? (Para 5-13, Para 7d (1a), AR
40-5) m. Does the hearing conservation officer
and or NCO have at least one year
retainability? n. Is DDForm 2215 complete and
on file in all medical records? (Para 7-7(b), DA
Pam 40-501) NOTES _________________________
_________________________________ ________________
__________________________________________ _______
__________________________________________________
_ ________________________________________________
__________ _______________________________________
___________________ ______________________________
____________________________ _____________________
_____________________________________ ____________
______________________________________________ ___
__________________________________________________
_____ VERIFICATION x_______________ Unit
POC Signature, Name, Rank, Date x______________
_ Inspectors Signature, Name, Rank, Date