Title Page

  • Facility Name

  • Playground Location within Facility (If Multiple)

  • Inspection Date

  • Personnel Conducting Inspection

  • Additional Personnel Present

  • Weather Conditions During Inspection

  • Was the playground in use during the inspection?

  • Did the public's presence prevent a full and complete inspection?

  • Please explain the extent to which the public's presence hindered the inspection.

A. Combination Units

  • Stairways/Step ladders

  • Please provide a description and photos of the risk(s).

  • Rigid Climbers

  • Please provide a description and photos of the risk(s).

  • Flexible Climbers (rope)

  • Please provide a description and photos of the risk(s).

  • Decks/Platforms

  • Please provide a description and photos of the risk(s).

  • Play Platforms

  • Please provide a description and photos of the risk(s).

  • Slides

  • Please provide a description and photos of the risk(s).

  • Sliding Poles

  • Please provide a description and photos of the risk(s).

  • Horizontal Ladders

  • Please provide a description and photos of the risk(s).

  • Crawl Tunnels

  • Please provide a description and photos of the risk(s).

  • Clatter/Other Bridges

  • Please provide a description and photos of the risk(s).

  • Ramps

  • Please provide a description and photos of the risk(s).

  • Roofs

  • Please provide a description and photos of the risk(s).

  • Other non-specified equipment

  • Please provide a description and photos of the risk(s).

B. Free Standing Equipment

  • Seesaws

  • Please provide a description and photos of the risk(s).

  • Slides

  • Please provide a description and photos of the risk(s).

  • Rigid Climbers

  • Please provide a description and photos of the risk(s).

  • Flexible Climbers

  • Please provide a description and photos of the risk(s).

  • Upper Body Equipment

  • Please provide a description and photos of the risk(s).

  • Rocking Equipment

  • Please provide a description and photos of the risk(s).

  • Merry-Go-Round

  • Please provide a description and photos of the risk(s).

  • Spinner (<20"D)

  • Please provide a description and photos of the risk(s).

  • Sand Play Area

  • Please provide a description and photos of the risk(s).

  • Play Panels

  • Please provide a description and photos of the risk(s).

  • Stepping Pods

  • Please provide a description and photos of the risk(s).

  • Net Climber

  • Please provide a description and photos of the risk(s).

  • Swings (To & Fro)

  • Please provide a description and photos of the risk(s).

  • Trampoline

  • Please provide a description and photos of the risk(s).

  • Exercise Equipment

  • Please provide a description and photos of the risk(s).

  • Other non-specified equipment

  • Please provide a description and photos of the risk(s).

C. Site Amenities

  • Tables

  • Please provide a description and photos of the risk(s).

  • Drinking Fountains

  • Please provide a description and photos of the risk(s).

  • Bike Racks

  • Please provide a description and photos of the risk(s).

  • Accessible Parking

  • Please provide a description and photos of the risk(s).

  • Signs

  • Please provide a description and photos of the risk(s).

  • Trash Bins

  • Please provide a description and photos of the risk(s).

  • Fencing/Gates

  • Please provide a description and photos of the risk(s).

  • Trails and Paths

  • Please provide a description and photos of the risk(s).

  • Grills

  • Please provide a description and photos of the risk(s).

  • Benches

  • Please provide a description and photos of the risk(s).

  • Other non-specified equipment

  • Please provide a description and photos of the risk(s).

General Comments

  • Additional Comments

  • Actions Taken

  • Actions Required

  • Will a work order be submitted?

  • Submitted to

  • Date and time submitted

  • Method of submission

  • Inspector's Name and Signature

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