Title Page
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Site conducted
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Conducted on
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Prepared by
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Prepared by
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Location
Inspection Body
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Use the following inventory checklist to note whether or not each item is present.
While moving through the list of items ensure that the item is not only present but also not expired and in good usable condition. If these conditions are not met, then do not count the item as present in the inspection record.
For each equipment set being observed, consider not only the contents but also the condition of the jump kit itself.
Where a deficiency is observed, use the built-in tools to record your observations.
Create a new section for each equipment set which is inspected.
Quantities indicated below are minimums based on WSBC Guideline G3.16 (1.1), additional supplies may be added as appropriate.
Jump Kit
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Jump Kit Location
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Include a photo of the kit
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3 Blankets
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24 14 cm x 19 cm wound cleansing towelettes, individually packaged
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20 10 cm x 10 cm sterile gauze dressings, individually packaged
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4 10 cm x 16.5 cm sterile pressure dressings with crepe ties
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4 20 cm x 25 cm sterile abdominal dressings, individually packaged
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6 Cotton triangular bandages, minimum length of base 1.25 m
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2 5 cm x 4.5 m rolls of adhesive tape
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4 7.5 cm X 4 m conforming gauze bandages
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4 7.5 cm x 4.5 m crepe roller bandages
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1 14 cm stainless steel bandage scissors or universal scissors
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1 11.5 cm stainless steel sliver forceps
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4 Quick straps (a.k.a. fracture straps or zap straps)
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1 Windlass style tourniquet
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1 Pocket mask with a one-way valve and oxygen inlet
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6 Pairs of medical gloves (preferably non-latex)
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6 Medical masks (also known as procedure or surgical masks)
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2 Face shields (or safety eyewear)
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1 Waterproof waste bag
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1 Penlight or flashlight
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50 Sterile adhesive dressings, assorted sizes, individually packaged
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1 Bottle of sterile saline solution
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1 Face shield
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1 Tube of glucose gel
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1 Naloxone kit
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1 Bottle ASA 81
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2 Foam splints (SAM Splints)
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2 Ice packs
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2 Heat packs
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1 Tube Polysporin
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Patient assessment charts
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First aid records
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Is the jump kit in good usable condition?<br>(Clean, dry, free of defects and damage)
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Has the kit been retagged and sealed after inspection?
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Indicate the tag number affixed to the kit.
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Use this space to add any additional commentary for the kit which was not captured above.
Emergency Oxygen Kit Supply List
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Emergency oxygen kit location
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Include a photo of the kit
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1 Portable oxygen therapy unit consisting of a cylinder of compressed oxygen, a pressure regulator, a pressure gauge, a flow meter, non-rebreathing mask, and nasal cannula
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1 Oropharyngeal airway kit
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1 Manually operated self-inflating bag-valve mask with an oxygen reservoir
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1 Digital pulse oximeter (Test to ensure that the device is operational)
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1 Portable suction unit
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Is the emergency oxygen kit in good usable condition?<br>(clean, dry, free of defects and damage)
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Has the kit been retagged and sealed after inspection?
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Indicate the tag number affixed to the kit.
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Use this space to add any additional commentary for the kit which was not captured above.
Dressing Station
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Dressing Station Location
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Include a photo of the dressing station access way
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3 Blankets
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1 Refuse pail with lid
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1 Package of paper towels
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1 Bifocal magnifier with head strap, 12.5 cm focus
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1 Eye cup
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1 14 cm stainless steel bandage scissors or universal scissors
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1 11.5 cm stainless steel sliver forceps
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1 Penlight or flashlight
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24 14 cm X 19 cm wound cleansing towelettes, individually packaged
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1 150 ml liquid antibacterial soap
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4 Cold packs
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100 Sterile adhesive dressings, assorted sizes, individually packaged
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24 Sterile skin closures, individually packaged
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6 20 cm x 25 cm sterile abdominal dressings, individually packaged
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3 30 cm x 40 cm sterile abdominal dressings, individually packaged
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100 7.5 cm x 7.5 cm gauze sponges
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24 7.5 cm x 7.5 cm sterile gauze dressings, individually packaged
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24 10 cm x 10 cm sterile gauze dressings, individually packaged
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4 7.5 cm x 4.5 m crepe roller bandages
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2 10 cm x 16.5 cm sterile pressure dressings with crepe ties
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1 7.5 cm x 4.5 m adhesive crepe bandage
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2 2.5 cm x 4.5 m rolls of adhesive tape
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2 5 cm x 4.5 m rolls of adhesive tape
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2 5 cm x 1.8 m conforming gauze bandages
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2 7.5 cm x 4 m conforming gauze bandages
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6 Cotton triangular bandages, minimum length of base 1.25 m
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2 SAM splints or quick splint equivalent
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1 #01 4.5 m tubular finger bandage with applicator
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1 Kidney basin
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1 Wash basin
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1 Cold instrument sterilizer with supply of non-rusting germicidal solution
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1 Chair suitable for treating injured worker (with a non-porous surface or covered with non-porous material)
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Patient assessment charts
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First aid records
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Is the first aid room in good usable condition?<br>(clean, dry, free of defects and damage)
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Use this space to add any additional commentary for the box which was not captured above.
First Aid Room
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First Aid Room Location
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Include a photo of the first aid room access way
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3 Blankets
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1 refuse pail with lid
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1 Package of paper towels
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1 Eye lamp, self-illuminating, magnifying
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1 Eye cup
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1 14 cm stainless steel bandage scissors
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1 11.5 cm stainless steel sliver forceps
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1 15 cm stainless steel thin nosed plier-type forceps
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1 Universal scissors
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1 Penlight or flashlight
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36 14 cm x 19 cm wound cleansing towelettes, individually packaged
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1 150 ml liquid antibacterial soap
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6 Cold packs
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100 Sterile adhesive dressings, assorted sizes, individually packaged
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48 Sterile skin closures, individually packaged
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6 20 cm x 25 cm sterile abdominal dressings, individually packaged
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3 30 cm x 40 cm sterile abdominal dressings, individually packaged
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6 Sterile eye pads, individually packaged
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200 7.5 cm x 7.5 cm gauze sponges
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72 7.5 cm x 7.5 cm sterile gauze dressings, individually packaged
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72 10 cm x 10 cm sterile gauze dressings, individually packaged
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6 7.5 cm x 4.5 m crepe roller bandages
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4 10 cm x 16.5 cm sterile pressure dressings with crepe ties
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2 7.5 cm x 4.5 m adhesive crepe bandages
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2 2.5 cm x 4.5 m rolls of adhesive tape
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2 5 cm x 4.5 m rolls of adhesive tape
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4 5 cm x 1.8 m conforming gauze bandages
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4 7.5 cm x 4 m conforming gauze bandages
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6 Cotton triangular bandages, minimum length of base 1.25 m
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4 SAM splints or quick splint equivalent
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1 #0l 4.5 m tubular finger bandage with applicator
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1 Kidney basin
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1 Wash basin
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1 Cold instrument sterilizer with supply of non-rusting germicidal solution
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1 Chair suitable for treating injured worker with a non-porous surface or covered with a non-porous material
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1 Bed approximately 2 m long X 75 cm wide, with a mattress having a non-porous surface or covered with a non-porous material
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2 Pillows with a non-porous surface or covered with a non-porous material
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4 Sheets
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Patient assessment charts
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First aid records
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Automatic External Defibrillator<br>(Refer to AED inspection for instructions on AED evaluation)
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Is the first aid room in good usable condition?<br>(clean, dry, free of defects and damage)
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Are storage areas for first aid records locked against unauthorized access?
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Use this space to add any additional commentary for the box which was not captured above.