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Rental Helmets | 77<br />
HEAD ® PROTECTION TM POST-ACCIDENT HELMET INSPECTION REPORT<br />
Complete all sections and attach copies of all rental agreements, service records and other pertinent documents. Do not leave blanks<br />
and do not guess or speculate when the information called for is not known or available. Enter “unknown” or “n/a” where appropriate.<br />
Shop Name<br />
User information<br />
Helmet information<br />
<strong>RENTAL</strong> AGREEMENT NO.<br />
NAME ACCIDENT DATE<br />
HEIGHT<br />
WEIGHT AGE SEX (circle one)<br />
REPORTED INJURY AND CIRCUMSTANCES OF ACCIDENT<br />
M F<br />
SKI AREA SKI RUN OR LOCATION<br />
Other Equipment information<br />
Helmet Inspection Results<br />
Helmet Status<br />
Personnel<br />
SKIER/RIDER ABILITY<br />
HELMET MAKE HELMET MODEL PRODUCTION CODE (from inside label)<br />
HELMET SIZE SHELL COLOR SHOP INVENTORY NUMBER (if applicable)<br />
SKI / SNOWBOARD MAKE SKI / SNOWBOARD MODEL SKI / SNOWBOARD LENGTH<br />
SKI / SNOWBOARD SERIAL NO. SKI / SNOWBOARD <strong>RENTAL</strong> I.D. NO. (if applicable)<br />
SKI / SNOWBOARD BINDING MAKE AND MODEL SKI BINDING RELEASE SETTINGS (if applicable)<br />
Right Toe ............. Left Toe .............<br />
Right Heel ............. Left Heel .............<br />
BOOT MAKE & MODEL BOOT SIZE<br />
BOOT <strong>RENTAL</strong> I.D. NO. (if applicable)<br />
DESCRIBE ANY DAMAGE OR UNUSUAL CONDITIONS OF SKIS, BOARD, BOOTS, BINDINGS, GOGGLES OR OTHER EQUIPMENT<br />
YES NO<br />
N/A (check one)<br />
0 0 0<br />
Shell intact and undamaged<br />
0 0 0 Liner intact and undamaged<br />
0 0 0 Strap and buckles intact and undamaged<br />
0 0 0 All standard labels present and legible<br />
Retained by shop ....... Retained by customer .......<br />
Returned to distributor ....... Returned to inventory .......<br />
INSPECTION TECHNICIAN DATE<br />
REPORT REVIEWED BY DATE<br />
COMMENTS FOR ANY “NO” OR “N/A” ANSWERS<br />
COMMENTS