Information
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Clinic Name
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Conducted on
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Prepared by
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Personnel involved
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Address
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Staff can explain RACE and PASS?
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Staff can locate the Emergency Preparedness Guide (Red Manual) emergency contacts?
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Staff know their role in an emergency?
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Staff know who to call in the event of a utility failure?
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Staff know where Power Outage supplies are located, and supplies are properly secured?
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Evacuation Routes are clearly posted and accurate?
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Hallways are free of extra equipment, clear exit path is maintained?
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Doors are unobstructed and not propped open?
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Exit doors are unobstructed and open freely to the outside?
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Exit signs are visible and illuminated?
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Fire pulls and fire extinguishers are unobstructed?
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Fire extinguishers have monthly inspection and annual maintenance?
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Sprinkler heads have 18" clearance?
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Ceiling tiles are unstained?
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All equipment cords and plugs are in good repair?
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Dryer lint trap cleaned after each use?
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Eyewash stations are accessible and tested as warranted?
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All chemicals are stored appropriately and not left unattended?
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Staff know how to retrieve SDS?
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Biohazard rooms are clearly marked?
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Patient care equipment is inventoried and inspections are current?
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Staff know steps to follow for medical device malfunction?
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No extension cords in use?
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Lights are functional?
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No cracked/peeling paint or wallpaper?
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No holes in walls?
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Grab bars are securely fastened?
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Emergency call systems are working properly?
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AED safety check completed?
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Patient information is not in public view?
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Staff personal items stored appropriately?
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Staff and agency wear badges?
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Sensitive areas are secure?
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Medical Records?
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Storage/Supply rooms?
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HR/Employee files?
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Electrical/Mechanical closets secure and clean?
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Electrical panels in corridors are locked?
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Staff know how to handle a disruptive visitor?
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Compliance Manual is complete and up to date?
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Additional Comments