Inventory Checklist and Agreement

Inventory Checklist
I Employee Name certify that I have been provided the below listed equipment in conjunction with my duties for Homestead Home Health & Hospice. I understand that if I should not return the equipment upon my termination or resignation from Homestead Home Health & Hospice that I authorize the deduction of the value (listed below) from my paycheck. In addition, if lost or stolen, I am to report the incident immediately to Homestead Home Health & Hospice for replacement.
Stethoscope blanks Amount
BP Cuff blanks Amount
O2 SAT Monitor blanks Amount
Digital Thermometer blanks Amount
Carrying Bag blanks Amount
IPAD/Device blanks Amount
Work Phone blanks Amount
ID Badge blanks Amount
Lab Coat blanks Amount
Scrubs blanks Amount
Name
First NameLast Name
Signature
Clear
Date
MonthDayYear
Date

Inventory Checklist