Title Page

  • Conducted on

  • Prepared by

Store Room Environmental Safety

  • Exits clear

  • Floors free from spills and tripping hazards

  • No items within 18” of sprinkler head

  • Hair Nets by exits

  • Fire extinguisher not blocked

  • Hallway clear

Cleanliness culinary/dry storage

  • Floors free from spills

  • Vents clean

  • Sprinklers clean, dust free

  • Walls clean

  • Equipment

  • Ceilings

  • Hot water in hand sinks

  • Can opener clean<br>Veggie<br>Hot cook<br>

  • Cutting boards clean/correct type<br>Red- Raw Animal<br>Green-Produce<br>White- Cooked/Ready to eat

  • Cold Prep labeling/dating<br><br>Record item type and date expired

  • Cut gloves being used

  • Walk in cooler labeling/ dating<br><br>Record item type and date expired

  • Cook’s cooler labeling and dating<br><br>Record item type and date expired

  • Large Culinary Freezer (All items in sealed containers, properly labeled and dated)

  • Culinary cooler/ freezer log

  • No ice build up in freezer

  • Proper hand hygiene/ Glove use

  • Sanitation bucket in use<br>Random check 1 bucket

  • Towels in sanitation buckets

Patient Services

  • Vents clean, free of dust

  • Sprinklers free from dust

  • Walls clean

  • Floors clean

  • Equipment working and clean<br>Check gaskets and vents

  • Ceilings clean

  • Patient services cooler/freezer log complete

  • Patient service labeling/dating<br> (Dippers, CA fridges)

  • Dipper temp logs <br>Correct form in use, temps taken at appropriate times and with corrective action if needed

  • Dish Machine log completed

  • Dish machine pressure log filled out

  • Pot sink set up and sanitizer titration

  • Sanitation buckets in use <br>Random check 1 bucket

  • Carts cleaned

Retail

  • Vents clean, free from dust

  • Sprinklers free from dust

  • Walls clean

  • Floors clean

  • Equipment dust free and working

  • Ceilings clean

  • Hot water at hand sinks

  • Sanitation buckets in use<br>Random check 1 bucket

  • Soda nozzles clean

  • Steam table labeling and dating<br>Check boxed lunches<br>Record item type and date expired

  • Steam table Temp logs complete

  • Salad bar cooler labeling and dating<br>Record item type and date expired

  • Salad bar temp logs

  • Grill area labeling and dating<br>Record item type and date expired

  • Grill temp logs

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.