Title Page

  • Conducted on

  • Client / Site

  • Location
  • Prepared by

  • Personnel

  • Document No.

  • Old Score


Disclaimer The assessors believe the information contained within this risk assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on matters which were observed or came to the attention of the assessors during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.

Confidentiality Statement In order to maintain the integrity and credibility of the risk assessment processes and to protect the parties involved, it is understood that the assessors will not divulge to unauthorized persons any information obtained during this risk assessment unless legally obligated to do so.

Personal Protective Equipment (PPE) availability

  • Gloves

  • Please choose which gloves are available

  • Isolation Gown

  • Face Shield / Goggles

  • Surgical Mask

  • N95 Mask

  • Please choose which N95 Mask is available

Hand Hygiene Program

  • Alcohol Based Hand Rub Dispensers filled up

  • Alcohol Based Hand Rub Bottle available

  • Soap Dispenser filled up

  • Paper Towels available

Isolation Practices

  • Sign Precaution Hanged outside isolation room / or on curtain in case of cohorting

  • PPE kept outside isolation room / or beside bed in case of cohorting

  • Staff Compliance to Standard Precaution Practices

  • Isolation log book available

Medical Waste Segregation

  • No overfilling observed

  • No mixing disposal

  • No recapped needles

  • All containers kept clean


  • Double Buckets for Regular room available

  • Double Buckets for isolation room available

  • Double Buckets Containers kept clean

  • Is the area kept clean and no visible soil or dirt all horizontal and vertical surfaces (Please explain in the note down in case if non-compliant)

  • Is cleaning schedule available?

Environmental Disinfectant

  • Spray Disinfectant available (Please write the name of Disinfectant in the note down)

  • Floor Disinfectant available (Please write the name of Disinfectant in the note down)

  • Name of Audit Surveyor

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.