Information

  • Document No.

  • Store Number

  • Store Address

  • Enter Date

  • Survey Prepared by

  • Collect Coordinates Location
  • Store Manager's Name

1. Photo of the Front of the Store

  • Insert photo here.

2. Headroom and doorways

  • Do all the following doorways and areas listed below measure at least 80 inches from the floor to the lowest point from the ceiling (ex: pipe, light fixture, etc.)?

    If there are no objects (ex: pipe, light fixture, etc.), does the floor to ceiling measure at least 90 inches?

    If no, describe the area in detail, enter measurement and insert picture.

  • A. Manager's Office

  • B. Administrative Assistant Office

  • C. SIC Office

  • D. Break Room

  • E. Above Lumber Storage Bin

  • F. Above Restroom

  • G. Warehouse Mezzanine

  • H. Warehouse-Below Mezzanine

  • I. Pole Shed Pigeon Racking-Elevated Walking Surface

  • J. List any other area(s) not listed above.

3. Other Egress Components

  • 3. Is every door opening at least 28 inches wide? If no, describe location(s) and enter measurement(s) and insert picture.

  • 4. Are all exit discharge doors unlocked or can they be opened from the inside? If no, describe the location(s) and insert picture.

  • 5. Are all exit routes free of obstacles? If no, describe the location(s), obstacle(s) and insert a picture.

  • 6. Is there a handrail for each set of stairs? If no, describe location(s) and insert picture.

  • A. Does each handrail measure between 30 inches and 38 inches from the leading edge of the stair tread? If no, describe area(s), enter measurement(s).

  • 7. Does each set of stairs measure equal to or less than 8 inches rise and equal to or greater than 9 inches run? If no, describe the location(s) and enter dimension(s).

  • 8. Does each exit discharge door have an exit sign? If no, describe the location(s).

  • 9. Is each exit EXIT sign illuminated? If no describe location(s).

  • 10. Does each exit discharge door have hardware that requires only one motion to open? If no, describe location(s).

  • 11. Are all stand alone building(s) greater than 3000 square feet? If no, describe and insert picture.

  • 12. Are there at least two (2) exit discharges (walk doors) in all buildings greater than 3000 square feet?<br>

  • 13. Is the sales building equipped with an automatic fire sprinkler system?

  • 15. Is the warehouse building equipped with an automatic fire sprinkler system?

  • 16. Is the sales building attached to the warehouse building?

  • 17. Are all dead-enders less than 20 feet? If no, describe the area, enter measurement and insert picture.

  • Add sketch or hand written notes here if needed.

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.