GSH Monthly Med gas PM

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Alarm panels.

• MGA 0101 (ED Hallway)

  Safe

  At Risk

  N/A

• MGA 0102 ( ED Hallway)

  Safe

  At Risk

  N/A

• MGA 0109 (ED hallway)

  Safe

  At Risk

  N/A

• MGA 0110 (ED nurses station)

  Safe

  At Risk

  N/A

• MGA 0103 (Behind OR Redline)

  Safe

  At Risk

  N/A

• MGA 0104 ( OR nurses station)

  Safe

  At Risk

  N/A

• MGA 0105 ( 100 hallway)

  Safe

  At Risk

  N/A

• MGA 0106 (200 hallway)

  Safe

  At Risk

  N/A

• MGA 0107 (200 hallway)

  Safe

  At Risk

  N/A

• MGA 0108 (200 hallway)

  Safe

  At Risk

  N/A

Med gas valve boxes.

• MGZV 0102 ( ED hallway)

  Safe

  At Risk

  N/A

• MGZV 0103 (ED hallway)

  Safe

  At Risk

  N/A

• MGZV VAC/O2 ( ED hallway)

  Safe

  At Risk

  N/A

• MGZV 0114 ( ED hallway)

  Safe

  At Risk

  N/A

• MGZV 0104 (Behind OR redline)

  Safe

  At Risk

  N/A

• MGZV 0105 (Behind OR redline)

  Safe

  At Risk

  N/A

• MGZV 0106 (100 hallway)

  Safe

  At Risk

  N/A

• MGZV 0107 (200 hallway)

  Safe

  At Risk

  N/A

• MGZV 0110 (200 hallway)

  Safe

  At Risk

  N/A

• MGZV 0111 (200 hallway)

  Safe

  At Risk

  N/A

• MGZV 0112 (200 hallway)

  Safe

  At Risk

  N/A

• MGZV 0108 (Admin hallway)

  Safe

  At Risk

  N/A

• MGZV 0101 ( Admin hallway)

  Safe

  At Risk

  N/A

• MGZV 0113 ( Admin hallway)

  Safe

  At Risk

  N/A

Bulk oxygen tank.

• Is gate locked?

  Yes

  No

  N/A

• Are there any visible problems?

  Yes

  No

  N/A

• O2 inches of water.

  Yes

  No

  N/A

Portable gas tanks

• Is the tank room locked?

  Yes

  No

  N/A

• Are there any visible problems?

  Yes

  No

  N/A

• Are the full/empty tanks step reacted from each other?

  Yes

  No

  N/A

• Are the tank chained to the wall?

  Yes

  No

  N/A

• Person doing inspection.

  Sign