• Areas Surveyed

  • Conducted on

  • Area Details

  • Names of Area Managers

  • Prepared by

  • Document No.

Safety Management

1.0 Electrical Safety

  • 1.1 Cords, plugs, outlets, power strips & surge protectors are in good condition, are permanently attached and not hanging free or touching the floor

  • 1.2 Electrical panels have 36ā€¯clear access in front and Arc flash labeling.

  • 1.3 Child resistant outlets located in child accessible areas

  • 1.4 Extension cords are not used as a substitute for fixed wiring.

  • 1.5 Flexible cords are not run through doorways or similar openings.

  • Repeat Violation

2.0 Slip/Trip/Fall Hazards

  • 2.1 Carpeting, vinyl and floor tiles are in good repair (no bumps or tears)

  • 2.2 Walking and working surfaces are free of tripping hazards

  • 2.3 Wet floor signs are used consistently and appropriately

  • Repeat Violation

3.0 Storage

  • 3.1 Shelving is secured

  • 3.2 Items over 45 lbs are stored low

  • 3.3 No boxes or paper items on floor

  • 3.4 Shelving is at least 6" off floor and bottom shelf is solid and cleanable

  • 3.5 Storage areas are used appropriately and are clean and dry

  • 3.6 Only cleaning supplies stored under sink and locked if in patient accessible area

  • Repeat Violation

4.0 Lighting

  • 4.1 All lights work in area

  • 4.2 Battery operated lighting functions

  • 4.3 Exit signs are illuminated

  • 4.4 Lighting is suitable for the care, treatment and services provided

  • Repeat Violation

5.0 Egress

  • 5.1 Stairwells and exit corridors are not obstructed or used for storage

  • 5.2 Access to exit doors is not obstructed or blocked by storage or other items

  • Repeat Violation

6.0 Staff and Lip Knowledge/Safety

  • 6.1 Can describe or demonstrate methods of minimizing or eliminating physical safety risks

  • 6.2 Can describe or demonstrate actions to take in a Safety incident

  • 6.3 Can describe or demonstrate how to use reporting system to report Safety risks

  • (Score:____ out of _____people questioned could describe)

  • Repeat Violation

7.0 Furnishings & Equipment

  • 7.1 Are safe and kept in good repair

  • 7.2 Soiled linen and trash containers are 32 gal or less except in Utility Rooms

  • 7.3 Decorations, except paintings and photos, are non-combustible or treated to be fire retardant

  • 7.4 No photos of patients are visible

  • 7.5 Only GSO approved space heaters are used and only in non-sleeping staff areas

  • 7.6 Toasters, microwaves, and coffee makers are commercial grade only. Coffee makers have auto shutoff feature.

  • 7.7 No toaster ovens are present or in use

  • 7.8 Other than above, no heat producing cooking appliances are present or in use

  • 7.9 Compressed gas cylinders are used, handled & stored properly with required signage (Score ____ number of locations/_________ deficiencies)

  • Repeat Violation

8.0 Compliance with the Smoking Policy

  • 8.1 No evidence of smoking in unauthorized areas

  • 8.2 Designated smoking areas are physically separate from care, treatment and service areas

  • 8.3 Authorized smoking areas are clean, safe and kept in good repair

  • Repeat Violation

9.0 Emergency Communications

  • 9.1 All phones have legible stickers with the 3499 emergency number

  • 9.2 Where applicable, RED telephones are available and accessible

  • 9.3 Staff know how to use the RED phones

  • 9.4 Where required, weather radios are operable with fully charged back up batteries

  • Repeat Violation

Previous Rounds

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.