Title Page

  • Audit Title

  • Conducted on

  • Inspected By

  • Location
  • Division/Location:

  • Supervisor Coverage:

Division Observation:

  • Corridor:

  • Waiting Room:

  • Public restroom:

  • Staff restroom:

  • Nurse Station:

  • Staff lounge:

  • Med room:

  • ASR/Supply Room:

  • Pantry:

  • Patient Room:

  • PACU/OR/Procedure Room:

  • Soiled Utility room:

Chemical Disinfectant:

  • Disinfection wipe container lids closed and labeled correctly?

  • Chemical Dispensing unit in working condition?

  • Staff have knowledge of Disinfectant? (Name of Disinfectant)

  • Performex?

  • Clorox Hydrogen Peroxide?

  • Staff have knowledge of what “Dwell/Kill Time” mean? (Item stays wet for the 5 minutes, to disinfectant and kill all germs), If drys re-wet item.

Equipment/Hopper Closet:

  • Housekeeping carts clean and functional, free of unnecessary item?

  • Housekeeping carts put away when not in use?

  • Equipment clean? (Vacuums, buffers & carts)

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

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

  • Eye Wash sheets properly dated? (Unblocked)

  • 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?

  • Hand Hygiene Being Performed? (Observation of Evidence)

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.