Title Page

  • Audit Title

  • Conducted on

  • Inspected By

  • Location

Division Appearance: (Overall First Impression of area/unit)

  • Entrance to Area/Division Clean and Free of Debris/Dust?<br>

Housekeeping Cart/Equipment:

  • Housekeeping carts clean and free of unnecessary item?

  • Cart Locked and put away when not in use?

  • Disinfection wipe container lids closed and properly labeled?

  • Chemical Spray Bottles properly labeled?

  • Equipment clean? (Vacuums, buffers & carts)

Housekeeping/Hopper Closet:

  • Hopper rooms clean and in order? (No unnecessary items)

  • Chemical Dispensing unit in working condition?

  • Chemicals not stored above dry supplies, an below shoulder height? (Paper Products, Waste Bags.)

  • Eye Wash sheets properly dated/Signed-Initialed? (Unblocked)

  • Hopper Room locked when not in use?

Safety Education:

  • Staff have knowledge of R.A.C.E. (Rescue-Alarm-Contain-Extinguish) and P.A.S.S. (Pull-Aim-Squeeze-Sweep.)?

  • Does staff have knowledge of SDS? What is SDS? (Safety Data Sheets) Where is the SDS information located?

  • P.P.E. Available? (Gloves, Goggles is there evidence of use?)

  • Staff have knowledge of location of Fire Pull Stations?

  • Staff have knowledge of Dwell time for Disinfectant? (Name of Disinfectant)

  • Performex?

  • Clorox Hydrogen Peroxide Wipes? (OR Only)

  • Clorox Bleach Wipes? (North Only)

Soiled Utility Room:

  • Soiled Utility rooms cleaned & organized?

  • Green Trash & Red Bio Hazard carts cleaned & lined? (McClure Carts)

  • Hand Hygiene Being Performed? (Observation of Evidence) Foam In, Foam Out

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.