Title Page
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Site conducted
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Current Location/Site
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Conducted on
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Prepared by
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Personnel
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Do all stations have eyewash stations or bottles?
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Is the access to equipment free and clear of obstacles?
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Is the flow of water adequate? (Do not conduct test on portable units)
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Do valves operate freely with no leaks? (Do not conduct test on portable units)
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Are station identification signs in place?
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Is an inspection tag/sticker attached to each eyewash/shower?
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Is the front of the unit clear of tripping/slipping hazards?
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Are they located a maximum 10 seconds of unobstructed travel distance away and on the same level as the hazard?
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Is the solution within the portable unit(s) within the expiration period set by the manufacturer?
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Is the expiration date on any eyewash bottles within the expiration period?
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Comments/Actions Needed
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Inspector Signature
