Title Page
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Client / Site
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Location
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Conducted on
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Prepared by
General Safety
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Are drawers kept closed at all times when not actually in use?
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Are chairs and other furniture in good condition?
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Are all compressed gas cylinders that may be in your area secured from falling over?
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During the survey, were all staff observed using proper body mechanics?
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In areas where items are stored or placed overhead, is there ready access to a suitable step stool, stepladder, or similar device?
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In storage areas, are the heavier items stored at waist level, with the lightest objects placed on the higher shelves?
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Are all vehicles (carts, wheelchairs, etc.) in good operating condition?
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Has personal protection equipment (as required by MSDS or other standards) been provided to all employees needing it?
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Has staff been trained on how to inspect and use patient care equipment?
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Is the area free of clutter?
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Is excess paper and combustible material improperly stored creating a fire risk?
Fire & Disaster
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Are all fire alarm pull stations and fire extinguishers accessible?
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Does all staff know the locations of fire alarm pull stations?
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Does all staff know the locations of extinguishers in or near their work area?
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Does staff in the area know the proper reporting procedure if they find (or believe there may be) a fire?
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Is all storage kept at least 18" below the sprinkler head keeping sprinklers unobstructed?
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Are all containers of powders, liquids, and gases labeled as to contents?
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Are all areas in compliance with “No Smoking” policies?
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Are all areas, other than approved kitchens, free of Toasters or Toaster Ovens?
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If portable space heaters are used, are they the approved type?
Hallways, Stairs, & Exit Paths
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Are the corridors kept clear of obstructions?
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Are all wet floors marked with "CAUTION, WET FLOOR" (or similar) signs?
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Is carpeting secure to the floor, unfrayed, free from tripping hazards, and generally in good condition?
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Are hard floor surfaces secure and free of tripping and slipping hazards?
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Are floor surfaces uneven or in need of repair?
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Are all EXIT signs illuminated?
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When opened and then released, do all fire doors close and latch properly?
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Are stairwell handrails in good condition?
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Are stair treads in good condition?
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Are stairwells completely clear of obstructions and any objects?
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Is the housekeeping in this area adequate?
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Is access to electrical panels clear and not obstructed?
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Are all electrical switches & circuit breakers identified? If not, list the locations of those that are not on the back of this sheet.
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Are all electrical receptacles and cover plates in good condition?
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Are electrical cords and plugs in good condition?
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Check for damaged insulation, cut cords, splices, and tape wrapped around the cord - none of which should be present.
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Are only fused power strip extension cords, surge protectors, used (all 3 pins on the plug)?
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Does all electrical equipment in the area appear to be in good condition?
Electrical Safety
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Is access to electrical panels clear and not obstructed?
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Are all electrical switches & circuit breakers identified? If not, list the locations of those that are not on the back of this sheet.
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Are all electrical receptacles and cover plates in good condition?
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Are electrical cords and plugs in good condition? Check for damaged insulation, cut cords, splices, and tape wrapped around the cord - none of which should be present.
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Are only fused power strip extension cords, surge protectors, used (all 3 pins on the plug)?
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Does all electrical equipment in the area appear to be in good condition?
Laboratory
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Are the emergency showers, eyewash stations, and fire extinguishers accessible?
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Are aisles clear and unobstructed to permit ready access out of the area in case of fire or another emergency?
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Are flammable storage cabinets located out of hallways and exit paths?
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Are corrosives stored only on the lowest shelves?
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Are flammables, acids, and bases all stored separately from each other?
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Are all refrigerators labeled to indicate whether or not they are safe for the storage of flammables?
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Are all non-explosion proof refrigerators entirely free of flammables? Are all chemicals labeled to indicate their contents?
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Are all chemical containers labeled to indicate any hazard which may be present, i.e. TOXIC, CORROSIVE, FLAMMABLE, etc.?
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Are Material Safety Data Sheets (MSDS) available for ALL products in the laboratory?
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Are food products, including beverages of any sort, kept out of the laboratory work environment at all times?
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During the survey, were all staff wearing the appropriate lab clothing? (No open toed shoes, no shorts)
Vehicles
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Are the following items in good working condition:
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Oil Level
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Battery, Radiator, Brake and Windshield Washer Fluid Levels
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Battery Terminals, Air Filter
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Tires
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Rubber Hoses, Belts - (Fan, Generator, Alternator)
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Doors, Mirrors, Windshield and other Glass
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Head Lights, Signal Lights, Brake Lights, and Other Lights
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Windshield Wiper Blades, Arms and Motor Operation
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Safety Belt for Each Passenger
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Horn Works
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Other Items (Defroster, Mechanical Condition, Paint, etc.)
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Safety Equipment - (Bumper Jack, Lug Wrench, Flares, 5 lb. ABC Extinguisher, Bungee Cords and/or Equipment needed to secure loads)
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Mileage and Maintenance Log Used
Completion
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Recommendations
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Full Name and Signature of the Inspector