Title Page
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Facility Name
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Playground Location within Facility (If Multiple)
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Inspection Date
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Personnel Conducting Inspection
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Additional Personnel Present
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Weather Conditions During Inspection
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Was the playground in use during the inspection?
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Did the public's presence prevent a full and complete inspection?
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Please explain the extent to which the public's presence hindered the inspection.
A. Combination Units
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Stairways/Step ladders
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Please provide a description and photos of the risk(s).
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Rigid Climbers
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Please provide a description and photos of the risk(s).
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Flexible Climbers (rope)
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Please provide a description and photos of the risk(s).
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Decks/Platforms
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Please provide a description and photos of the risk(s).
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Play Platforms
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Please provide a description and photos of the risk(s).
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Slides
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Please provide a description and photos of the risk(s).
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Sliding Poles
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Please provide a description and photos of the risk(s).
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Horizontal Ladders
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Please provide a description and photos of the risk(s).
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Crawl Tunnels
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Please provide a description and photos of the risk(s).
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Clatter/Other Bridges
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Please provide a description and photos of the risk(s).
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Ramps
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Please provide a description and photos of the risk(s).
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Roofs
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Please provide a description and photos of the risk(s).
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Other non-specified equipment
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Please provide a description and photos of the risk(s).
B. Free Standing Equipment
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Seesaws
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Please provide a description and photos of the risk(s).
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Slides
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Please provide a description and photos of the risk(s).
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Rigid Climbers
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Please provide a description and photos of the risk(s).
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Flexible Climbers
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Please provide a description and photos of the risk(s).
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Upper Body Equipment
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Please provide a description and photos of the risk(s).
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Rocking Equipment
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Please provide a description and photos of the risk(s).
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Merry-Go-Round
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Please provide a description and photos of the risk(s).
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Spinner (<20"D)
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Please provide a description and photos of the risk(s).
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Sand Play Area
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Please provide a description and photos of the risk(s).
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Play Panels
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Please provide a description and photos of the risk(s).
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Stepping Pods
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Please provide a description and photos of the risk(s).
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Net Climber
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Please provide a description and photos of the risk(s).
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Swings (To & Fro)
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Please provide a description and photos of the risk(s).
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Trampoline
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Please provide a description and photos of the risk(s).
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Exercise Equipment
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Please provide a description and photos of the risk(s).
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Other non-specified equipment
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Please provide a description and photos of the risk(s).
C. Site Amenities
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Tables
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Please provide a description and photos of the risk(s).
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Drinking Fountains
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Please provide a description and photos of the risk(s).
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Bike Racks
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Please provide a description and photos of the risk(s).
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Accessible Parking
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Please provide a description and photos of the risk(s).
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Signs
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Please provide a description and photos of the risk(s).
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Trash Bins
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Please provide a description and photos of the risk(s).
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Fencing/Gates
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Please provide a description and photos of the risk(s).
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Trails and Paths
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Please provide a description and photos of the risk(s).
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Grills
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Please provide a description and photos of the risk(s).
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Benches
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Please provide a description and photos of the risk(s).
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Other non-specified equipment
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Please provide a description and photos of the risk(s).
General Comments
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Additional Comments
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Actions Taken
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Actions Required
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Will a work order be submitted?
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Submitted to
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Date and time submitted
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Method of submission
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Inspector's Name and Signature