Information

  • Clinic Name

  • Conducted on

  • Prepared by

  • Personnel involved

  • Address
  • Staff can explain RACE and PASS?

  • Staff can locate the Emergency Preparedness Guide (Red Manual) emergency contacts?

  • Staff know their role in an emergency?

  • Staff know who to call in the event of a utility failure?

  • Staff know where Power Outage supplies are located, and supplies are properly secured?

  • Evacuation Routes are clearly posted and accurate?

  • Hallways are free of extra equipment, clear exit path is maintained?

  • Doors are unobstructed and not propped open?

  • Exit doors are unobstructed and open freely to the outside?

  • Exit signs are visible and illuminated?

  • Fire pulls and fire extinguishers are unobstructed?

  • Fire extinguishers have monthly inspection and annual maintenance?

  • Sprinkler heads have 18" clearance?

  • Ceiling tiles are unstained?

  • All equipment cords and plugs are in good repair?

  • Dryer lint trap cleaned after each use?

  • Eyewash stations are accessible and tested as warranted?

  • All chemicals are stored appropriately and not left unattended?

  • Staff know how to retrieve SDS?

  • Biohazard rooms are clearly marked?

  • Patient care equipment is inventoried and inspections are current?

  • Staff know steps to follow for medical device malfunction?

  • No extension cords in use?

  • Lights are functional?

  • No cracked/peeling paint or wallpaper?

  • No holes in walls?

  • Grab bars are securely fastened?

  • Emergency call systems are working properly?

  • AED safety check completed?

  • Patient information is not in public view?

  • Staff personal items stored appropriately?

  • Staff and agency wear badges?

  • Sensitive areas are secure?

  • Medical Records?

  • Storage/Supply rooms?

  • HR/Employee files?

  • Electrical/Mechanical closets secure and clean?

  • Electrical panels in corridors are locked?

  • Staff know how to handle a disruptive visitor?

  • Compliance Manual is complete and up to date?

  • Additional Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.