Tourniquet Inspection Checklist Form
Document the results of your routine tourniquet inspection using this checklist.
Date of Inspection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Name
*
Tourniquet Serial/ID Number
*
Is the tourniquet clean and free of visible contamination?
*
Yes
No
Not Applicable
Are all straps and buckles intact and undamaged?
*
Yes
No
Not Applicable
Does the windlass rod rotate smoothly and lock securely?
*
Yes
No
Not Applicable
Checklist: Select all issues found during inspection
Frayed strap
Cracked/broken buckle
Stiff or jammed windlass
Visible contamination
Label unreadable
No issues found
Overall Condition
*
Pass
Fail
Needs Repair
Location of Tourniquet
Additional Comments or Notes
Submit Inspection
Should be Empty: