• Document No.

  • Audit Title

  • Site

  • Conducted on

  • Prepared by

  • Location

Previous Inspections

  • Items from previous inspections have been addressed ?


  • Work/Storage Areas - safe and accessible (proper shelving used/secure, no above head hazards, heavier items on the bottom) ?

  • Work/Storage Areas - Clean and Clear (no excessive clutter) ?

  • Eye wash/shower station are tested weekly and documented?


  • Staff, volunteers, vendors appropriately identified ?

  • Valuable items secured ?

  • Other

Hazardous Materials/Waste

  • Hazardous Chemicals - properly labeled/stored ?

  • Infectious Waste Containers (rigid, labeled, covered) ?

  • Infectious Waste Storage (Soiled Utility Rooms) - Doors to storage area closed/monitored or secured ?

  • Waste Disposal - Appropriate disposal of waste in proper container ?

  • Lead Aprons - Uniquely identified ?

  • Other

Emergency Preparedness

  • Emergency numbers posted (33333 on the phones) ?

  • Other

Fire Safety

  • Fire Doors - Not propped open (door wedges), Unit entrance doors - positively latch ?

  • Fire Exits - Clear, Correctly marked (Exit Signs), unlocked from inside, clear of debris/equipment ?

  • Sprinklers - 18" clearance ?

  • Fire Alarm/Pull Station - 3 ft. clearance ?

  • Oxygen/Gas Cylinders - Stored upright, secured on the top and bottom 3rd to prevent falling, in a stand/ cart, no more than 12 "E" cylinders per smoke compartment ?

  • Electrical Cords / strip outlets Not overloaded/daisy chained, In good repair, Extension cords not used ?

  • Fire Extinguishers Clearly marked, 3 ft. clearance, On wall or in cabinet, Pressure gauges read full ?

  • Appliances<br>- Major appliances (high wattage) plugged directly into a wall outlet, Clear from combustibles<br>- All appliances (especially those with a metal exterior) must have a three-prong plug (ground wire) to prevent fire and electrocution<br>- No hot-plates, fryers, hot air or easybake ovens, toasters, or toaster ovens allowed<br>- Microwaves are clean and free from loose debris inside and all vents are clear<br>- No open element space heaters<br>- Hot shots are clearly marked as 'hot, boiling water'

  • Ceiling tiles set in place properly and no gaps in the ceiling to allow smoke to enter ?

  • Other

Medical Equipment

  • Other

Physical Environment

  • Work/Storage Areas - Clean, Free from hazards/clutter ?

  • Floors/Walkways/Walls/Ceilings - In good condition, Clean, Dry, No penetrations, Adequate lighting, Construction-no signs of dust/debris ?

  • All items in storage are at least 4" off the floor

  • Other

Dietary / Nutrition

  • Refrigerators - Clean, Employee and Patient Food separated, Patient food labeled/dated, Temperature Logs current (for patient refrigerators only)?

  • Other

Infection Prevention

  • Staff eating or drinking in designated areas only ?

  • Hand gel/soap dispensers functioning and contain current product ?

  • Under sink storage clear (nothing allowed under sinks)?

  • Cubicle curtains are free of visible soil ?

  • Dirty linen storage - room secured?

  • Linen covered in (inside or outside of the clean utility room)?

  • Medication refrigerators log maintained (review follow up if temperatures were out of range)?

  • High Level Disinfection - Daily and QC logs complete?

  • Test Strips in a closed bottle and inside a cabinet?

  • Other


  • Fixtures in good condition (no damage to outlets, outlet cover and light switches (char marks, cracks, discoloration ?)

  • Mechanical / Electrical / Communication rooms – clear of combustible material storage ?

  • Lights/Fixtures - covered/protected (diffusers not cracked or missing) ?

  • Med Gas Panel - 3 ft. clearance, Shut off zone identified ?

  • Electrical Panels - closed/covered, secured ?

  • Return / Supply air ducts in the ceiling clean (not covered with dust) ?

  • Appropriate areas (isolation rooms, toilets, soiled utility rooms, etc.) have negative pressure.

  • Other

Staff Knowledge

  • Reporting Accidents/Incidents ?

  • Back up/alternate communication systems ?

  • Code Pink ?

  • Code Gray ?

  • Hazardous Chemicals in the Area ?

  • Accessing SDSs ?

  • Code Violet ?

  • Code Red - RACE, PASS, Extinguisher/Fire Alarm Pull Station locations, Primary/Secondary Exits, Evacuation - horizontal/vertical ?

  • Oxygen Shut Off ?

  • Code Triage (Staff's role in a disaster - stand by and respond when/where needed) ?

  • Clinical Interventions for Equipment Failures ?

  • Utility Failure Procedures ?

  • How do you know if equipment is clean?

  • How and when to use the proper PPE?

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.