Tourniquet Application Checklist
Record and verify each step of proper tourniquet use in emergency or clinical settings.
Date and time of tourniquet application
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Name of person applying the tourniquet
*
First Name
Last Name
Indication for tourniquet use
*
Severe limb bleeding
Traumatic amputation
Uncontrolled hemorrhage
Other (specify below)
Tourniquet applied to which limb?
*
Left arm
Right arm
Left leg
Right leg
Was clothing removed to expose the limb at the application site?
*
Yes
No
Tourniquet placement distance from wound
*
2-3 inches above wound
Directly over joint
Other (specify below)
Was the tourniquet tightened until bleeding stopped?
*
Yes, bleeding stopped
No, bleeding continued
Not applicable
Was a distal pulse checked after application?
*
Yes, pulse absent
Yes, pulse present
Not checked
Was the time of application documented on the patient?
*
Yes
No
Complications observed after application
*
None
Skin injury
Nerve injury
Persistent bleeding
Other (specify below)
Additional notes or observations
Submit Checklist
Should be Empty: