EOC Rounds Template

EOC Rounding SSM Healthcare St Louis

• Facility

  Select CGMC SMHC DPHC SJHC SJHW SJHC WZ SCHC Other

  • CGMC
  • SMHC
  • DPHC
  • SJHC
  • SJHW
  • SJHC WZ
  • SCHC
  • Other

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Data Collection

• Description of Deficiency

Item to Correct

• Facility

  Select CGMC SMHC DPHC SJHC SJHW SJHC WZ SCHC Other

  • CGMC
  • SMHC
  • DPHC
  • SJHC
  • SJHW
  • SJHC WZ
  • SCHC
  • Other

• Floor

  Select 1st floor 2nd floor 3rd 4th 5th 6th 7th 8th 9th 10th Basement Ground

  • 1st floor
  • 2nd floor
  • 3rd
  • 4th
  • 5th
  • 6th
  • 7th
  • 8th
  • 9th
  • 10th
  • Basement
  • Ground

• Room Number

• Is 'Responsible Leader' Plant Operations?

  Yes

  No

• Who?

• Description of Deficiency

• Photo

  Media

• Life Safety Priority

  1

  2

  3

• Type

  Select IC Security Utilities Safety Life Safety Equipment Hazmat Fire Safety Other

  • IC
  • Security
  • Utilities
  • Safety
  • Life Safety
  • Equipment
  • Hazmat
  • Fire Safety
  • Other

• Corrected On-Site?

  Yes

  No

Questions or Follow Up Items

• Question or Follow Up Items

Questions

• Question:

• Who are you responding to?

• Sign this Field

  Sign

• Great work!

Equipment

• Is there any faulty equipment?

Equipment

• Model #

• Serial #

• Is anyone at fault?

• Who?

Person

• Name

• Employee #