Title Page

  • Building

  • Facility

  • Floor

  • Room

  • Conducted on

  • Prepared by

  • Location


  • Instructions
    1. Answer "Excellent", "Good", "Fair", "Poor" for the items below. Choose N/A if not applicable.
    2. Add photos and notes by clicking on the paperclip icon. (Specify the room number in the notes)
    3. Complete audit by providing digital signature.
    4. Share your report by exporting as PDF, Word, Excel or Web Link.


  • Interviewee

  • Employee

  • Supervisor

Customer Survey

  • Rate the cleanliness of your area.

  • Rate the responsiveness of our staff to your requests.

  • Rate the availability of restroom and patient area supplies.

Quality Tour Comments

  • Patient Room 1

  • Patient Room 2

  • Patient Room 3

  • Med Room

  • Nurses Station

  • Staff Lounge

  • Staff Restroom

  • Clean Utility Room

  • Soiled Utility Room

  • Family Waiting Room

  • Family Waiting Room RR

  • Corridors

  • Computer Room

  • Elevators

  • Stairwells

  • Comments


  • 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.