EVS Quality Inspection - Ancillary

• Location/Room #

• Conducted on

  Date

• Manager Conducting Audit

• EVS Staff Member Assigned

Door Surfaces

• Frames and Top Edges

  PASS

  FAIL

  N/A

• Push Plates and Handles

  PASS

  FAIL

  N/A

• Hinges

  PASS

  FAIL

  N/A

Walls/Wall Hangings

• Light Switches

  PASS

  FAIL

  N/A

• Pictures/Frames

  PASS

  FAIL

  N/A

• TV/Bracket

  PASS

  FAIL

  N/A

• Clocks

  PASS

  FAIL

  N/A

Ceilings

• Lights Clean

  PASS

  FAIL

  N/A

• Vents are clean and free of dust on outsides

  PASS

  FAIL

  N/A

• No visible spots on Ceilings/Tiles

  PASS

  FAIL

  N/A

Horizontal Surfaces

• Counters

  PASS

  FAIL

  N/A

• Ice Machines

  PASS

  FAIL

  N/A

• Shelves/Cabinet Tops - free of dust

  PASS

  FAIL

  N/A

• Fire Strobe Lights/Exit Lights - Free of dust

  PASS

  FAIL

  N/A

• Phone and Cord - Clean and Organized

  PASS

  FAIL

  N/A

• Railings and Ledges - Free of Dust

  PASS

  FAIL

  N/A

Windows

• Glass Doors

  PASS

  FAIL

  N/A

• Windows - No Smears

  PASS

  FAIL

  N/A

• Window Sills

  PASS

  FAIL

  N/A

• Mirrors - No Marks

  PASS

  FAIL

  N/A

• Blinds/Curtains - No Spots

  PASS

  FAIL

  N/A

Furniture

• Chairs/Sofas clean including the legs

  PASS

  FAIL

  N/A

• Tables and Legs

  PASS

  FAIL

  N/A

• Lamps/Shades

  PASS

  FAIL

  N/A

• Garbage Cans - Clean, Extra Bags and Relined

  PASS

  FAIL

  N/A

Floors

• Floors are clean

  PASS

  FAIL

  N/A

• No build up in corners

  PASS

  FAIL

  N/A

• Baseboards are Clean

  PASS

  FAIL

  N/A

• Carpet free of debris and spots

  PASS

  FAIL

  N/A

• No dust bunnies behind doors or equipment

  PASS

  FAIL

  N/A

MISC.

• Hallway Sinks Clean

  PASS

  FAIL

  N/A

• Employee Signature when Available:

  Sign

• Manager conducting Audit

  Sign

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