Form 2 ASC M. Audit

Monthly Operational Audit

• Room No.

  Room 1

  Room 3

  Growth Room

• Type of Laser Equipment

  Candela Gentle Lase Mini

  Candela Gentle Yag Mini

  Candela Gentle Lase Pro

  Candela Gentle Yag Pro

• Date of Audit

  Date

Records

• Are the User Daily Operationial Checklists conducted

  Yes

  No

• Are the User Daily Operationial Checklists reviewed for non-compliances?

  Yes

  No

• Is the RSPF (Radiation Safety Protection Folder) reviewed for non-compliances?

  Yes

  No

• Are all non-compliances recorded on the Corrective Actions Register and kept in the RSPF?

  Yes

  No

• Are all incident / accidents reported on The Village?

  Yes

  No

First Aid and Fire Protection

• Emergency evacuation plans visible and valid?

  Yes

  No

• Fire equipment free of obstruction and tagged?

  Yes

  No

• Emergency evacuation route free of obstruction?

  Yes

  No

Non beam Hazards

• No hazardous chemicals in area?

  Yes

  No

• High voltage equipment located away from wet surfaces or water sources

  Yes

  No

Housekeeping

• Room clean, dust free, clear of trip hazards and reflective materials?

  Yes

  No

• Has the laser filter been checked and and is clean?

  Yes

  No

Signage

• Warning, radiation output, class and illuminated signage in good condition?

  Yes

  No

• Warning labels permanently fixed and clearly visible on all equipment per the class of laser being used?

  Yes

  No

• In accordance with Test 16 of HR006:2010 labels are affixed close to each aperture which bears the words "Laser Aperture" (Yellow label black words) - label on machine and handpiece?

  Yes

  No

Controlled Area

• Area restricted to authorised users only?

  Yes

  No

• Beam path kept below eye level?

  Yes

  No

• Anodized or matte-finish instruments used?

  Yes

  No

Equipment Integrity

• Manufacture operational and instructional manual in laser room?

  Yes

  No

• Cords, handpiece returned to original standby mode positioning when not in use?

  Yes

  No

• No wear and tear to hose, valves, fittings and interlocks?

  Yes

  No

• No damage to external housing, cords, articulated arm or optical fibre?

  Yes

  No

• Emergency switches tested?

  Yes

  No

Additional Notes

• Notes:

Non-conformance Details

• Details:

Acknowledgement

• Name of Auditor:

• Signature:

  Drawing