Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location


  • 1. Are ceiling tiles seated flush, stained, missing, or broken

  • 2. Is the floor clean and not damaged?

  • 3. Is the Hand sanitizer installed above, below, or closer than one inch (25 mm) to an electrical receptacle, switch, appliance, device, or other ignition source?

  • 4. Is there damage to walls, wallpaper, baseboards,

  • 5. Is there any evidence of pest or bugs in light fixtures

  • 6. Are ceiling vents free of dust, rust, or dirt

  • 7. Are there outside shipping cardboard boxes in storage areas or any clinical areas

  • 8. Is Clean and Dirty storage separated? No dirty items in clean and no clean items in dirty

  • 9. Eyewash stations have inspection tages and are up to date

  • 10. Refrigerator temperatures are being monitored


  • 1. Are sprinkler heads free of dust

  • 2. Are Oxygen, Med gas shutoff valves, FEs, and pull stations blocked?

  • 3. Are fire extinguishers charged and inspected within 30-day intervals?

  • 4. Storage is below 18 inches of sprinkler heads.

  • 5. All department doors latch properly, and are doors not propped or blocked?

  • 6. Exit signs properly in place and fully illuminated

  • 7. Are hallways free from clutter?

  • 8. Integrity of smoke and fire doors are intact with no paper or decorations

  • 9. No storage in the stairways?

  • 10. Corridor storage of equipment - plugged into outlets - moves in 20 minutes?


  • 1. Staff wearing ID badges?

  • 2. Have the security doors been comprised (combinations written in view, door propped, staff sharing combination


  • 1. Linen carts are covered and nothing on top?

  • 2. No cardboard boxes on floor?

  • 3. Are refrigerator temperature logs current daily / values in range?

  • 4. Refrigerator log form is current

  • 5. Is patient care equipment clean and cleaned between patients, not dusty, free from tape?


  • 1. Staff can demonstrate PASS & RACE and what to do if this was an actual fire

  • 2. Does the staff know where to find information on emergency codes and emergency plans?

  • 3. Staff displays knowledge of available evacuation equipment and how to obtain it.


  • 1. Bio-hazard rooms are labeled and secured, including all soiled utility rooms

  • 2. Cleaners, chemicals are properly labeled and secured

  • 3. Sharps containers are secured and not overfilled?


  • 1. Absence of HIPAA violations, no open charts?

  • 2. Is patient health information in the correct containers and not in department wastepaper baskets?

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.