Title Page

  • Conducted on

  • Prepared by

  • Branch

HVAC

  • Is the branch on Smart Building

  • HVAC #1 Equipment Location

  • Notes

  • Equipment Service area

  • Notes

  • HVAC Manufacturer

  • HVAC Model #

  • Date Maufacturered

  • Notes

  • AC Condenser Unit

  • Location

  • Condenser coils cleaned

  • Notes

  • Filter Size

  • Filter Changed

  • Belt Size/Part #

  • Belt Changed

  • Wall thermostat Manufacturer

  • Model#

HVAC #2

  • HVAC #2 Equipment Location

  • Notes

  • Equipment Service area

  • Notes

  • HVAC Manufacturer

  • HVAC Model #

  • Date Maufacturered

  • Notes

  • AC Condenser Unit

  • Location

  • Condenser coils cleaned

  • Notes

  • Filter Size

  • Filter Changed

  • Belt Size/Part #

  • Belt Changed

HVAC #3

  • HVAC #3 Equipment Location

  • Notes

  • Equipment Service area

  • Notes

  • HVAC Manufacturer

  • HVAC Model #

  • Date Maufacturered

  • Notes

  • AC Condenser Unit

  • Location

  • Condenser coils cleaned

  • Notes

  • Filter Size

  • Filter Changed

  • Belt Size/Part #

  • Belt Changed

HVAC #4

  • HVAC #4 Equipment Location

  • Notes

  • Equipment Service area

  • Notes

  • HVAC Manufacturer

  • HVAC Model #

  • Date Maufacturered

  • Notes

  • AC Condenser Unit

  • Location

  • Condenser coils cleaned

  • Notes

  • Filter Size

  • Filter Changed

  • Belt Size/Part #

  • Belt Changed

Wash Bay Heater, Unit #1

  • Type of heater, Unit #1

  • Notes

  • Gas or Electric

  • Notes

  • Unit #1 location

  • Manufacturer

  • Model #

  • Notes

  • Unit #1 Overall Condition

  • Notes

Wash Bay Heater, Unit #2

  • Type of heater, Unit #2

  • Notes

  • Gas or Electric

  • Notes

  • Unit #2 location

  • Manufacturer

  • Model #

  • Notes

  • Unit #2 Overall Condition

  • Notes

Wash Bay Heater, Unit #3

  • Type of heater, Unit #3

  • Notes

  • Gas or Electric

  • Notes

  • Unit #3 location

  • Manufacturer

  • Model #

  • Notes

  • Unit #3 Overall Condition

  • Notes

Wash Bay Heater, Unit #4

  • Type of heater, Unit #4

  • Notes

  • Gas or Electric

  • Notes

  • Unit #4 location

  • Manufacturer

  • Model #

  • Notes

  • Unit #4 Overall Condition

  • Notes

Phone System

  • Manufacturer

  • Notes

  • Model #

  • Does the phone system have a back up battery power supply? Most would be APC brand.

  • Manufacturer and Model #

  • Notes

  • System Location

Camera System

  • Does the branch have a security camera system in place?

  • Manufacturer

  • Model #

  • Service Provider/Installer

  • Notes

  • DVR/monitor location

  • User name

  • Password

  • System is in good working condition? All cameras provide a clear view and picture on the monitor.

  • What is wrong with the camera system? What follow up is needed?

  • Camera #1

  • Interior or Exterior?

  • Placement/location

  • Camera #2

  • Interior or Exterior?

  • Placement/location

  • Camera #3

  • Interior or Exterior?

  • Placement/location

  • Camera #4

  • Interior or Exterior?

  • Placement/location

  • Camera #5

  • Interior or Exterior?

  • Placement/location

  • Camera #6

  • Interior or Exterior?

  • Placement/location

  • Camera #7

  • Interior or Exterior?

  • Placement/location

  • Camera #8

  • Interior or Exterior?

  • Placement/location

  • Camera #9

  • Interior or Exterior?

  • Placement/location

  • Camera #10

  • Interior or Exterior?

  • Placement/location

  • Camera #11

  • Interior or Exterior?

  • Placement/location

  • Camera #12

  • Interior or Exterior?

  • Placement/location

  • Camera #13

  • Interior or Exterior?

  • Placement/location

  • Camera #14

  • Interior or Exterior?

  • Placement/location

  • Camera #15

  • Interior or Exterior?

  • Placement/location

  • Camera #16

  • Interior or Exterior?

  • Placement/location

Safes

Floor Safe #1

  • Location

  • Manufacturer

  • Model #

  • Battery type

  • Quantity of batteries

  • How to access the battery(ies)

  • Notes

  • Battery(ies) replaced

  • Notes

Floor Safe #2

  • Location

  • Manufacturer

  • Model #

  • Battery type

  • Quantity of batteries

  • How to access the battery(ies)

  • Notes

  • Battery(ies) replaced?

  • Notes

Wall Safe #1

  • Location

  • Manufacturer

  • Model #

  • Battery type

  • Quantity of batteries

  • How to access the battery(ies)

  • Notes

  • Battery(ies) replaced?

  • Notes

  • Does the branch have the back-up key (circular, barrel shaped key) to access the wall safe if the batteries die?

  • What is the key cylinder code? Locate the cylinder by removing the small plastic cover (some have the brand name on the cover)

Wall Safe #2

  • Location

  • Manufacturer

  • Model #

  • Battery type

  • Quantity of batteries

  • How to access the battery(ies)

  • Notes

  • Battery(ies) replaced?

  • Notes

  • Does the branch have the back-up key (circular, barrel shaped key) to access the wall safe if the batteries die?

  • What is the key cylinder code? Locate the cylinder by removing the small plastic cover (some have the brand name on the cover)

EPLEX door locks

  • Batteries replaced

  • How many EPLEX door locks are onsite?

  • Are they in good working order?

  • Notes

Door lock Cylinder Preventative Maintenance

  • All lock cylinders lubricated with Tri-Flow? (doors, pad locks, etc)

  • What follow up is needed to PM each cylinder?

Fire Extinguishers & Emergency Lighting

  • All Fire Extinguishers ANNUAL inspection completed January 2019? (The tag will be punched on the month and year)

  • What date was their last ANNUAL inspection?

  • Is Cintas the service provider on the inspection tag?

  • Who is the provider?

  • Are they compliant? Good working order, charge gauge in the green, pin intact, no damage

  • What follow up must be completed?

  • Notes

  • How many extinguishers are onsite?

Location of each fire extinguisher

  • Location #1

  • Location #2

  • Location #3

  • Location #4

  • Location #5

  • Location #6

  • Location #7

  • Location #8

  • Location #9

  • Location #10

  • Location #11

  • Location #12

  • Location #13

  • Location #14

  • Location #15

Emergency Lighting

  • Tested each unit for good working order

  • What follow up is needed?

  • Location of unit(s) needing repair

  • Service provider (most will be Cintas)

  • Provider name

Location of each Emergency Light/Exit sign

  • Location #1

  • Location #2

  • Location #3

  • Location #4

  • Location #5

  • Location #6

Eye Wash Station

  • Eye wash station onsite in the wash bay?

  • Manufacturer

  • Model #

  • How many are onsite?

  • Are they in good working order to provide 15 minutes of consistent water? (Test for 30 seconds)

  • What follow up is needed?

  • Location (if more than one eye wash station is onsite)

  • Wall sign is visible and in good condition?

  • What follow up is needed?

  • Location (if more than one eye wash station is onsite)

  • Wall bracket in good condition? If rusted = fail

  • Dust caps in good condition?

  • No active leaks?

  • Notes/Comments

Water Quality

  • Water Softner

  • Manufacturer

  • Model #

  • Gallons

  • Date installed or manufactured

  • Water softner salt needed?

  • Notes

  • Hot Water Heater

  • Manufacturer

  • Model #

  • Gallons

  • Date installed or manufactured

  • Does hot water run from the sink?

  • Is the pilot light out? Are the electric heater elements out?

  • Follow up needed

  • Notes

  • Does the hot water feel scolding hot?

  • Lower the temp

  • What follow up is needed?

  • Anode rode need replacement?

  • Notes

  • Hot water heater flushed out

  • What follow up is needed to flush it out?

  • Water quality?

  • Does it smell like iron? rust color to the water? Toilet stained orange from the iron

  • Are the faucet aerator in good working order? Not caked up with mineral deposits? Water flow is sufficient?

  • Location of failed aerator

  • Size/thread needed

  • If on well water do they have a pressure tank

  • Condition of pressure tank?

  • Service provider sticker on pressure tank?

  • Do they have an iron filter?

  • Condition of iron filter?

  • Service provider sticker on iron filter?

  • Notes

Carpet and Paint

  • Carpet in good condition

  • Measure out the whole office or area where replacement is needed

  • Take a photo of your drawing with measurements

  • Paint in good condition (Interior)

  • What accent wall color is needed

  • Notes

  • Door and window jambs/sills/moldings in good condition?

  • What needs to be painted our tradedress black?

  • Paint in good condition (Exterior)

  • Do we have our tradedress, moderate white on the exterior?

  • Notes

Restroom

  • Flooring in good condition

  • Tradedress ceramic tile

  • If ceramic tile is needed, measure the space for floor and a 4' tall boarder on the walls

  • Take a photo of your drawing with measurements

  • Walls in good condition

  • What follow up is needed?

  • Fixtures look current and not tired/old/rusted out

  • Take photos of current fixtures

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.