BLADE TYPE ISSUED

BLADE CONTROL RECORD

BLADE TYPE ISSUED

(AR, FP, SH, SC)ISSUED BY

ISSUERS

SIGNATUREISSUED TO

(NAME AND KNIFE ID. CODE)DATETIMERECEIVERS

SIGNATUREOLD BLADE RETURNED

INTACT YES / NO(IF NO COMPLETE REVERSE)

ISSUERS

SIGNATURE

RECEIVERS

SIGNATUREREASON FOR NON RETURN OF BLADE/RETURN OF A DAMAGED BLADEACTION TAKENDATETIME

BLADE TYPE KEY = Automatic Retractable (AR), Folding Pen (FP), Sheath (SH), Scalpel (SC)

HD 16.17 Revision 1

PAGE 1 OF 2

Issue Date: 15.02.00