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First Aid Kit Order Form

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First Aid Kit Order Form Powered By Docstoc
					                                               First Aid Kit Supply Order
Instructions: Department supervisors are responsible for ensuring First Aid Kits are routinely
inspected for supplies. If First Aid Kit supplies are needed, the department supervisor must complete
and submit this form to Human Resources. Please check only those items you need to order, and for
those items list the Quantity Needed and Outstanding amount left-on-hand. Sign and date at the
bottom.

Name:
:
Position:
Department:
Location of First Aid Kit:



Check if      Quantity
Needed        Needed         Outstanding   Description
                                          Band Aids
                                          Latex Gloves
                                          Cold Packs
                                          Adhesive Tape
                                          Eye Wash Cup
                                          2 X 2 Inch Gauze or Woven Pads
                                          3 X 3 Inch Gauze or Woven Pads
                                          4 X 4 Inch Gauze or Woven Pads
                                          Triangular Bandage
                                          Burn Antiseptic Spray
                                          Ammonia Inhalants
                                          Elastic Bandage
                                          Bloodborne Compliance Cleanup Kit
                                          First Aid Facts Informational Guide




Supervisor Signature and Date (Required)

X


                     SUBMIT THIS FORM TO HUMAN RESOURCES

				
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posted:2/15/2011
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