and/or decontamination before the First Aid kit is available for use again.
Main Checklist Table
| ITEM | SIZE | AMOUNT SUPPLIED | AMOUNT USED |
|---|---|---|---|
| Medical | |||
| Alcohol Prep Pads | 1" x 1" | 16 | |
| Antiseptic Towelettes | 1" x 1" | 15 | |
| Band-Aids, Cloth | 1" x 3" | 20 | |
| Blood Blocker | 5" x 5-1/2" | 1 | |
| Cold Packs | 2 | ||
| Combine Pads | 5" x 9" | 3 | |
| Eye Wash | 1 oz. | 1 | |
| Gauze Sponges | 2" x 2" | 5 | |
| Gauze Sponges | 3" x 3" | 5 | |
| Gauze Sponges | 4" x 4" | 5 | |
| Gloves | Box of 2 pair | 1 | |
| Insect Sting Pad | Box of 10 | 1 | |
| Knuckle, Cloth | 1.5" x 3" | 20 | |
| Rescue Blanket | 1 | ||
| Rescue Breather Mask | 1 | ||
| Rolled Gauze | 2" x 2.5" yards | 1 | |
| Rolled Gauze | 4.5" x 4.1 yards | 1 | |
| Tape, Roll | 1" x 10 yards | 1 | |
| Triangular Bandage | 1 | ||
| SWAT-T Tourniquet | 1 | ||
| Israeli Emergency Bandage | 1 | ||
| Pelican Type Case | |||
| Non Medical | |||
| Ball Point Pen | 1 | ||
| Checklist | 1 | ||
| EVS-14 Emergency Response | Form | 1 | |
| EVS-16 Report of Mishap | Form | 1 | |
| Seal | 1 | ||
| Trauma Shears | 1 | ||
| Zip lock Bags | |||
Usage Information Table
| Used By: | Organization: | ||
|---|---|---|---|
| Class #: | Date items used: |
Restocking and Contact Table
| Name of person receiving the unit as used (print): | Date: | Time: | |||
|---|---|---|---|---|---|
| Restocked and placed in service by: | Date: | Time: | |||
| New Seal Number: | |||||
| Name (print) or contact person | Signature of contact person |
|---|---|
Routing Instructions
Routing: Forward completed form to PT Contact Person: Forward completed form to the office of the Safety Specialist
Name
Name
Form may be photocopied
Name
Name
Form may be photocopied
