INDUSTRIAL HYGIENE INSPECTION FORM

Audit Title

Client / Site

Personnel

Cleanliness of Slats and Shelves

Stability of Materials

Food Properly Stored on Shelves / Slats - Not Floor

Leftovers Properly Covered and Labeled with time and date when stored

No leftovers older than 48 hours

General Housekeeping

Comments (Identified Problems) and actions taken:

Personnel free from Open Lesions

Personnel free from Respiratory Signs /Symptoms

Clean Uniforms

Good hand washing practices

Use of gloves and hats / hairnets

Sanitary work practices

Comments (Identified Problems) and actions taken:

Sinks /Drains clean and clear of waste / sanitized daily with logs

Dishwasher at proper temperature ( 165 degrees F. or higher)

Waste properly Disposed of

General Housekeeping

Comments (Identified Problems) and actions taken:

Pots / pans, and utensils properly stored - clean and dry

Fire extinguisher

Fire blanket

Mat slicer clean -guard properly installed

Can opener

Mixing machine

Ranges, hoods, and filters clean -free of grease buildup

Exhaust vents clear of dust buildup

CO2 system for range (fire extinguishers)

Trash regularly removed

Floors free of slip and trip hazards

Comments (Identified Problems) and actions taken:

Tables and chairs clean

All sauces, dressings, condiments, etc. in date

All perishables in refrigerator

Milk machine

Coffee mess clean and stocked

Ice machine

Drink machines

General housekeeping

Comments (Identified Problems) and actions taken:

Proper storage on pallets or shelves

Stability of materials

All containers, bags, and boxes properly sealed

All items in date

General housekeeping

Comments (Identified Problems) and actions taken:

Floors

Lavatories and mirrors

Sower floors, walls and spigots

Showers cleaned with bleach solution (anti- fungus)

Soap dishes

Benches and shelves

Mops, brooms, clean buckets and properly stored

Urinals and commodes cleaned and sanitized

Toilet paper and paper towels stocked

Use of disinfectants

Waste bins emptied

Comments (Identified Problems) and actions taken:

Floors and passageways clean

Walls and handrails

Lighting- normal and emergency

Escape routes clearly identified

Use of disinfectant

Comments (Identified Problems) and actions taken:

Floors cleaned and exit path clear

Lighting

Muster map posted

Use of disinfectant

Waste bins emptied

Linen changed weekly

Towels changed daily

Comments (Identified Problems) and actions taken:

Lighting

Handrails

Passageway clear-no trip, slip hazards

General housekeeping

Comments (Identified Problems) and actions taken:

Floors

Chairs, benches

Waste bins emptied

General housekeeping

Comments (Identified Problems) and actions taken:

All fountains and spigots cleaned daily

Drains free of debris

Use of disinfectants

Comments (Identified Problems) and actions taken:

Dryer filters free of dust and lint buildup

Machines clean

Proper storage of detergents

General housekeeping

Clean folding area

Comments (Identified Problems) and actions taken:

Over All Comments :