Form 3 ASC A. Audit

Operational Audit (Bi-Annual)

• Clinic Location

• 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

Licence & Conditions

• Is the possession licence appropriate for the radiation practices conducted?

  Yes

  No

• Is the possession licensee complying with the condition stated on the license?

  Yes

  No

Laser Safety Officer

• Has the person who holds a relevant Laser Safety Officer Certificate been appointed as LSO?

  Yes

  No

• Date of Attainment

  Date

• Has the LSO been carrying out the functions stated in the RSPP?

  Yes

  No

Inventory

• Do the radiation sources/apparatuses and their locations math the inventory?

  Yes

  No

Compliance

• Does each apparatus in use have a current certificate of compliance and do they remain in compliant with the relevant standard?

  Yes

  No

• Date of Certificate

  Date

• Does each premise have a current and appropriate certificate of compliance and do they remain in compliance with the relevant standard?

  Yes

  No

• Date of Certificate

  Date

Radiation Safety and Protection Plan (RSPP)

• Is there a RSPP appropriate for the radiation practice?

  Yes

  No

• Do users have access to the RSPP?

  Yes

  No

• Is access to, or use of radiation apparatuses adequately controlled?

  Yes

  No

Use of apparatuses

• Are safety checks / QA checks conducted as described in the RSPP?

  Yes

  No

Records

• Are all records required by the RSSP being maintained?

  Yes

  No

Transport

• Is transport of radioactive substance carried out by licensed persons authorised under the act if applicable?

  Yes

  No

Supply of Safety Devices

• Are safety devices supplied, used and checked as described in the RSPP?

  Yes

  No

Supply of Personal Protective Equipment

• Is personal protective equipment supplied and checked as described in the RSPP?

  Yes

  No

Integrity of Personal Protective Eyewear

• No sign of pitting, grazing, cracking and discoloration of material?

  Yes

  No

• No damage to straps, frame and retaining devices?

  Yes

  No

• No light leaks and coating damage?

  Yes

  No

Supply of Radiation Monitoring Equipment

• Is equipment supplied used, checked and calibrated as described in the RSPP?

  Yes

  No

Additional Notes

• Notes:

Non-conformance Details

• Details:

Acknowledgement

• Name of Auditor:

• Signature:

  Drawing