Title Page
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Conducted on
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Prepared by
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Location
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Name of room or room number
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Personnel present
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Select type of room inspected.
- Lecture room
- Classroom
- Meeting room
- Office
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Is the ceiling clean and in good condition?
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Are carpets clean and undamaged?
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Is the floor clean and in good condition?
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Are all the lights clean and in good operating condition?
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Are the horizontal surfaces clean and in good condition?
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Are the vertical surfaces clean and in good condition?
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Are the waste containers clean and in good condition?
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Are Windows clean?
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Is the white board clean and in good condition?
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Are the blinds/shades clean and in good operating condition?
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Are the doors and door frames clean and in good operating condition?
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Has the DSE within the room received a workstation assessment?
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Is the furniture clean and in good condition?
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Is there appropriate Fire Assembly / Evacuation notices within the room?
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The room is free of any Fire Fighting Equipment?
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Name and signature of inspector
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Date of signature
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Name/s and signature/s of any staff accompanying inspector
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Date of signature
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Name and signature of Manager responsible for room
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Date of signature
