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F77 First Aid Kit
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9
Form
9
F77 First Aid Kit
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Unique ID
SITE NAME
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SITE LOCATION
Type of Kit
Fixed
Carry On
Frequency of Service
Weekly
Monthly
Quarterly
Annually
Last service date
DD slash MM slash YYYY
Item
1. Adhesive Tape 2.5cm x 5m Zinc Oxide
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Adhesive Tape 2.5cm x 5m Zinc Oxide)
2. Adhesive Tape paper 2.5cmx5M
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Adhesive Tape paper 2.5cmx5M)
3. Antiseptic Cream
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Antiseptic Cream)
4. Antiseptic Wipes
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Antiseptic Wipes)
5. Band Aids – Packets
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Band Aids – Packets)
6. Burn Dressing – Large
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Burn Dressing – Large)
7. Burn Dressing – Small
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Burn Dressing – Small)
8. Burnaid Gel
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Burnaid Gel)
9. Cold/Heat Pack
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Cold/Heat Pack)
10. Combine Dressing 20x20cm
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Combine Dressing 20x20cm )
11. Conforming Bandage 10cm x 1.8m
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Conforming Bandage 10cm x 1.8m)
12. Conforming Bandage 5cm x 1.8m
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Conforming Bandage 5cm x 1.8m)
13. Conforming Bandage FAC 7.5cm x 1.8m
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Conforming Bandage FAC 7.5cm x 1.8m)
14. Cotton Buds 7.5cm
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Cotton Buds 7.5cm)
15. CPR Resuscitation Card
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (CPR Resuscitation Card)
16. Crepe Bandage – Large
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Crepe Bandage – Large)
17. Crepe Bandage – Small
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Crepe Bandage – Small)
18. Crepe Medium Bandage 10cm x 2m
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Crepe Medium Bandage 10cm x 2m)
19. Crepe Medium Bandage 7.5cm x 2m
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Crepe Medium Bandage 7.5cm x 2m)
20. Cup Plastic Disposable 180ml 6oz each
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Cup Plastic Disposable 180ml 6oz each)
21. Disposable Gloves
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Disposable Gloves)
22. Dressing Pack Basic
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Dressing Pack Basic)
23. Emergency Thermal Blanket
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Emergency Thermal Blanket)
24. Eye Pad Single
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Eye Pad Single)
25. Eye Wash Solution
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Eye Wash Solution)
26. First Aid Booklet
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (First Aid Booklet)
27. Gauze Pieces 7.5cm Sterile
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Gauze Pieces 7.5cm Sterile)
28. Gloves Latex Pair Large - Pre Packed
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Gloves Latex Pair Large - Pre Packed)
29. Healaid Cream
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Healaid Cream)
30. Kidney Dish Plastic Green 160mm
Select One
Compliant
Improvement Possible
Non-Compliant
Not Applicable
Number Used (Kidney Dish Plastic Green 160mm)
31. Magnifier Plastic
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Magnifier Plastic)
32. Non-Adherent Dressing 7.5X10cm
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Non-Adherent Dressing 7.5X10cm)
33. Non-Adherent Dressing 7.5X5cm
Select One
Compliant
Improvement Possible
Non-Compliant
Not Applicable
Number Used (Non-Adherent Dressing 7.5X5cm)
34. Notebook and Pencil
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Notebook and Pencil)
35. Penlight Disposable With Pupil Gauge
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Penlight Disposable With Pupil Gauge)
36. Plastic Bag Clip Seal Plain
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Plastic Bag Clip Seal Plain)
37. Pressure Pads
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Pressure Pads)
38. Register Of Injuries
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Register Of Injuries)
39. Resusi-Safe Shield Disposable
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Resusi-Safe Shield Disposable)
40. Safety Pins Assorted
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Safety Pins Assorted)
41. Saline 10ml Pods
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Saline 10ml Pods)
42. Scissor S/S 12.5cm Sharp/Blunt
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Scissor S/S 12.5cm Sharp/Blunt)
43. Sharps Disposal
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Sharps Disposal)
44. Splinter Probe Disposable
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Splinter Probe Disposable)
45. Thermometer
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Thermometer)
46. Triangular Bandage Disp 110cmx155cm
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Triangular Bandage Disp 110cmx155cm)
47. Triangular Bandage Disp 96 x 96cm
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Triangular Bandage Disp 96 x 96cm)
48. Tweezers
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Tweezers)
49. Wound Dressing No 15
Select Status
Adequate supply
Topped up
Resupply required
NA
Number Used (Wound Dressing No 15)
Total
Have you attached the INJURY RECORDS Relevant to this Period Service Report?
Yes
No
Name
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Signature
Date
DD slash MM slash YYYY
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