Title Page

  • Conducted on

  • Location


Disclaimer The assessors believe the information contained within this risk assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on matters which were observed or came to the attention of the assessors during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.

Confidentiality Statement In order to maintain the integrity and credibility of the risk assessment processes and to protect the parties involved, it is understood that the assessors will not divulge to unauthorized persons any information obtained during this risk assessment unless legally obligated to do so.


Personal Protective Equipment (PPE) availability

  • Gloves

  • Please choose which gloves are available

  • Isolation Gown

  • Face Shield / Goggles

  • Surgical Mask

  • N95 Mask

  • Please choose which N95 Mask is available

  • If answer is other write down

Hand Hygiene

  • Alcohol Based Hand Rub wall Dispensers filled up

  • Alcohol Based Hand Rub Bottle available

  • Soap Dispenser filled up

  • Paper Towels available

Isolation Practices when applicable

  • Negative Pressure Room Monitoring

  • Sign Precaution Hanged outside isolation room / or on curtain in case of cohorting

  • PPE kept outside isolation room / or beside bed in case of cohorting

  • Isolation log book available

Medical Waste Segregation

  • No overfilling observed

  • No mixing disposal

  • No recapped needles

  • All containers kept clean


  • Double Buckets for Regular room available

  • Double Buckets for isolation room available

  • Double Buckets Containers kept clean

  • Is the area kept clean and no visible soil or dirt all horizontal and vertical surfaces (Please explain in the note down in case if non-compliant)

  • Is cleaning schedule available?

Environmental Disinfectant

  • Spray Disinfectant available (Please write the name of Disinfectant in the note down)

  • Floor Disinfectant available (Please write the name of Disinfectant in the note down)

  • Write down any other remarks

  • IPC Practitioner

This section is approval of receiving a copy of the evaluation for the department that has been evaluated

  • Acknowledgment of receipt of the report

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.