• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Are corridors free of stored items?

  • Are corridors free of flammable materials?

  • Are evacuation plans current?

  • Are Exit signs properly lit?

  • Do battery-operated emergency lights work properly? (if applicable)


  • Are stairwell doors clear of blocking materials?

  • Is stairwell lighting working properly?

  • Are all stair treads intact?

  • Is proper exiting signage posted in stairwell?

  • Are stairwells free of storage?

Anesthesia Work Room

  • Are life safety conditions met in this space?

Equipment Storage/Storage Rooms

  • Do items on the floor meet appropriate storage requirements?

  • Are stored items below the 18" ceiling sprinkler plane?

  • Storeroom doors are not held or wedged open?

  • Is the door to the room kept locked when unoccupied?

  • Are sprinkler heads unobstructed?


  • Are life safety conditions met in these spaces?


  • Are life safety conditions met in these spaces?


  • Are EVS carts being kept out of the corridors when not in use?

  • Are EVS closets kept locked?

  • Is EVS equipment stored in appropriate places?

Fire/Smoke Doors

  • Do fire/smoke doors close properly?

  • Are fire/smoke doors free of blocking items on both sides of the doors?

Electrical/Telephone Rooms

  • Is the door to the room locked when not in use?

  • Rooms do not contain inappropriate storage items?

Medical Gases

  • Are the medical gas shutoff valves clearly labeled?

  • Is staff aware of responsibility for shutting off medical gases during an emergency and where gas shutoff valves are located?

  • Are gas shutoff panels clearly accessible?

  • Are all oxygen tanks secured properly?

Fire Safety

  • Do staff know where fire alarm pull stations are located?

  • Are all fire pull stations accessible and do they appear to be in working order?

  • Have fire extinguishers been checked, and the tag marked properly?

  • Are fire sprinkler escutcheon plates all properly in place?

Surgical Suites

  • All flooring is in good condition?

  • Does surgical suite door positively latch?

  • Do electrical outlets appear to be in good condition?

  • Do all room lights work properly?

Sub-Sterile Alcoves

  • Is flooring in alcove in good condition?

  • Does room lighting appear to be working properly?


  • Are all rooms clearly labeled to assist emergency response personnel?

Linen/Utility Rooms

  • Linens and pillows are not on the floor?

  • Are items stored on the floor appropriately?

  • Is room storage below the 18" ceiling fire sprinkler restriction?

  • Is the door to the room kept closed when not in use?

  • Are the doors to the utility rooms unblocked?

Male Locker Room

  • Are life safety conditions met in this space?

Female Locker Room

  • Are life safety conditions met in this space?


  • Extension cords are not in use?

  • No paper signs are posted in the area?

  • All cabling is dresses appropriately under work surfaces?

General Comments

  • Are life safety conditions1 met?

  • Are life safety conditions2 met?

  • Are life safety conditions3 met?

  • Are life safety conditions4 met?

  • Are life safety conditions5 met?

  • Are life safety conditions6 met?

  • Are life safety conditions7 met?

  • Are life safety conditions8 met?

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.