Title Page
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Client / Site
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Conducted on (Date and Time)
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Inspected by
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Location
Checklist
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Gauze pads (at least 4 x 4 inches)
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Two large gauze pads (at least 8 x 10 inches)
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Box adhesive bandages (band-aids)
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One package gauze roller bandage at least 2 inches wide
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Two triangular bandages
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Wound cleaning agent such as sealed moistened towelettes
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Scissors
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At least one blanket
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Tweezers
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Adhesive tape
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Latex gloves
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Resuscitation equipment such as resuscitation bag, airway, or pocket mask
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Two elastic wraps
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Splint
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Directions for requesting emergency assistance
Completion
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Additional Supplies Needed
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Name and Signature of Inspector