9

8
7
6
5
4
3
2
1

31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
EX
Date
Si

X
gn
a ge
in
cli
ni
ci

X
O2 nd
Office of Clinical Services

/N ica
2

Created: 2/2012 Revised: 2/2013

co O te
nt 2 sl
en Cy oc
l i at
O2 ts nde io
n

X
Cy r sa of
50 lin re O2
0 de
ps r c l ea /N
i is rly 2O
fu
m 2
Cy ll a
lin nd ar
d ke
X
tip er re d
pi s s ad id
en
University of Washington School of Dentistry

ng to yf
, f red or tif
al us yi
lin in e ng
go am w
Cy r r an i t h
X

lin o lli ne a
de ng r t PS
rs o I>
st pr
or ev
Cy ed e nt
X

lin in ha
de w za
el
rs
se l ve rd
cu nt by
re ila
Cy d te
lin up d
X

fla der rig ar

ht ea
m sa
m re
ab 2
le 0 f
, o ee
ri ta
W nc w
om ay
hi
l
X

pa fro
an e tu t ia m
d/ n r b l co
or ed e
ho on su mb
sin in bs us
g i sp ta tib
n c le
Em f a ec es ,
X

pp t fo
pt li ca le r
se y ta
pa n b le ks a
ra ks ar
ou
X

Ni te a are
tr r c nd
ou eas lea va
sT rly lv
an m es
ks ar
ho k ed
X

Ni
tr sin
o ga
an
d
P o us st
lic tan nd or
y ks va ed
st l ve in
o
X

Ni
tr
o r e si
d ns
cr us in pe
ac sc se ct

Page 1
ks av cu ed
en re fo
gi
X

Ni lo rl
tr ng c ea
ou un at ks
st i io
t n
an
kc
in
sp p er
Po on ec SO
rta te te
d D
nt fo
in ble
cli O
sg
re r le
ni 2 E at ak
c: er so
__ me th r
Em __ rge an
er __ nc 5 0
ge __ y
__ a B 0
ps
nc g: i
yO In
Na 2 di
c
sa Ta at
lC nk e
an Qt
nu In yl
sp oc
la ec at
No pa te ed
n- ck d
ag an
Monthly Oxygen/Nitrous Oxide Cylinder Inspection Checklist

Re
br ed d
ea an Fu
th d ll
Ba er un
gV m d a
al as
ka m
ve ag
M va
ila
ed
as bl
St ki e
af n
fM ta
em ct
an
be d
rs op
in ea
iti ra
al
s bl
e
Notes

R:\deans\OCS- OPS\Health-Safety\Templates\Oxygen-Nitrous Checklist 2012

Month/Year___________________
Department___________________