Information

  • Document No.

  • Audit Title

  • Conducted on

  • Prepared by

  • Complex

  • Building

  • Location
  • Personnel Present

Concern

  • Concern(s)

  • Complaint

General

  • Odours?

  • Stuffy?

  • Overcrowding?

  • Unsanitary Conditions?

  • Garbage/Recycling Emptied Regularly?

  • Dust?

  • Moisture Problems? AC unit, condensation, etc...

  • Staining and discolouration of ceilings, tiles, walls, or carpets?

  • Visible Mould?

  • Are large amounts of paper stored, moved, or shredded?

  • Presence of chemical substances?

  • Very new or old furniture, fabrics, etc.?

  • Are any areas currently being, or have they recently been, remodelled, repaired, or redecorated?

  • Compare the original use of the complaint area and surrounding space with the present use.

  • General Comments

  • General Area Photos

Temperature

  • Enter Temperature Reading

  • Temperature
  • Location

  • Temperature

  • Any local sources of heating or cooling? Ex. Solar load or cold through windows, personal heaters, fans, AC units...

  • Thermal Gradient?

  • Floor-to-ceiling differential should not exceed 3 degrees C.

Humidity

  • Ideal indoor humidity levels are 35% in the winter and 50% in the summer. ASHRAE specifies a range between 25-60%.

  • Enter Relative Humidity Reading

  • RH
  • Location

  • Relative Humidity

  • Condensation?

  • Humidifier Operation?

  • Chemical additives for water treatment?

Ventilation/Air Flow

  • ASHRAE recommends that average air movement not exceed 0.15 m/s for winter periods and 0.25 m/s for summer periods.

  • Enter Air Flow Reading

  • Air Flow
  • Location

  • Air Flow

  • Comments

  • Balanced Air Distribution? Use of fans...

  • Obstruction of Airflow?

  • Are air diffusers located directly above people?

  • Are air intakes located near exhaust outlets, parking areas, smoking areas... Etc.?

Air Samples

  • Direct Reading Tube Sampling

  • Sample
  • Substance

  • Reading

  • Comments

  • Pull Tube Photo

  • Integrative Air Samples Required? If so list potential parameters and locations.

  • Are Dustrak readings required?

  • Dustrak Readings

  • Reading
  • Reading

  • Location

  • Average particulate concentration found in buildings is 10 ug/m3 in a non-smoking environment, and can range from 30-100 ug/m3 in smoking areas.

Affected Employees

  • Number of Employees Affected

  • Affected Employees

  • Employee
  • Employee Name

  • Employee ID

  • Symptoms

  • Other

  • Suspected Cause(s)

Conclusion/Follow-Up

  • Suspected Cause(s)

  • Action Items

  • Action
  • Action Item

  • Assigned To

  • Due

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.