• Department of State Assessment Screening

  • Site/Destination

  • Conducted on

  • Prepared by

Audit Processing

General Compliance

  • Standard Policy signs clearly visible

  • First aid signs clearly visible

  • Lighting adequate and operational

  • Temperature is comfortable

  • Area is free from odours

  • Noise level is acceptable/adequately controlled

  • Ventilation is adequate

  • Stair treads in good condition

  • Handrails present, safe and secure

  • Electrical equipment tested, tagged and safe

  • Electrical switches/sockets in good condition


  • Access and egress paths clear

  • First aid kit accessible

  • Fire fighting equipment easily accessible

  • Fire fighting equipment checked in last 6 months

Title 45 Code Compliance Public Works

  • Seating available and safe

  • Tables safe and clean

  • Policy ,Rule, Bill Of Rights Posted

  • Supervisor on Site View

  • Emergency Safeguard Procedure

  • Adequate Notice Procedure Form

  • Client’s Receipt of Appearance

  • Assessment Request Form(s) Compliance Article 10

Sec.195 Misconduct/Fraud/Disclosures

  • Employee Behavior

  • Communication to Visitors

  • Report and Forms in Filing

  • Chain of Command Names Produced

  • E Workers Available to Enrollees

  • Article 10 Fair Hearing To Clients Rts

  • HIPPA Form Management Processed

  • Power of Authority Known

Sign Off

  • Violations/Civil Offense

  • On site representative

  • Auditor's signature

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.