• Document No.

  • General Audit Title

  • Conducted on

  • Prepared by

General Hospital Information

  • Hospital/Clinic Name

  • Photo of Hospital/Clinic

  • Address
  • Phone No.

  • Doctors Name

  • Doctors Email

  • Head Nurses Name

  • Head Nurses Email

  • Technician/s

  • Technicians email

  • Number of Patients

  • Number of Dialysis Stations

  • Number of ICU Points



  • Raw water tank/s and booster pump/s

  • Add media

  • Sand/Media Filter-Size-Valve Type- Backwash Flowrate

  • Sand/Media Filter

  • Water Softener-Brine Tank Setup

  • Water Softener & Brine Assembly

  • Carbon Filtration

  • Does the Carbon Filter meet the required EBCT

  • Carbon Filters

  • Cartridge Filtration

  • Cartridge Filter

  • Brand of Reverse Osmosis System/Manufacturer

  • Model I.e. How many membranes? Output of System? Year of Installation?

  • Does the Reverse Osmosis Meet ISO 26722

  • Reverse Osmosis System Photo

  • General comments on Reverse Osmosis System

  • Bypass

  • General Comments of Bypass Arrangement

  • Bypass Photos

  • Distribution System type

  • Loop Material

  • Loop Size

  • Approximate Loop Length

  • Loop & Outlet Points

  • General Comments of Loop & Outlet Points

  • General Comments of WTS Equipment

Reverse Osmosis Tank

Reverse Osmosis Tank (ROT)

  • Brand/Manufacturer

  • Size of Tank in Litres

  • Photo of ROT

  • General Comments of ROT



  • Number - Make - Model - Age

  • Photos of Portable WTS Equipment

  • General Comments on Portable WTS Equipment


Reprocessor Equipment

  • Number-Make-Model-Age

  • Photo of Reprocessing Equipment

  • General Comments of Reprocessing Equipment

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.