CHSS Safety Medic Audit

• Document No.

• Conducted on

  Date

• Client Site:

  VCMC

• Prepared by

• Location
  Address

• Additional Personnel at Time of Inspection:

• Observation 1

• Contractor Observed

• Photos of observation:

  Media

• Action taken (if any):

• Further action needed?

  Yes

  No

  N/A

• Observation 2

• Contractor Observed

• Photos of observation:

  Media

• Action taken (if any):

• Further action needed?

  Yes

  No

  N/A

• Observation 3

• Contractor Observed

• Photos of observation:

  Media

• Action taken (if any):

• Further action needed?

  Yes

  No

  N/A

• Observation 4

• Contractor Observed

• Add media

  Media

• Action taken (if any):

• Further action needed?

  Yes

  No

  N/A

Additional Comments (if needed)

• Additional comments

• Add media

  Media

Inspectors signature

• Add signature

  Sign