Safety Manuals are present in the program area?
Employees are aware how to access Safety and Infection Control Policies?
Hazard Assessments completed for all employees (random selection-review with supervisor)?
Radiological Operating and Safety Procedures Present?
Annual sign off by Radiation Safety Officer and operators?
Equipment Inspections/Calibrations up to date (i.e. scales/thermometers/lab and radiology equipment)?
Equipment in good condition (no frayed cords, broken plugs, etc.)?
Broken Equipment taken out of service until repaired?
Electrical & Fire
Power cords (3 prong, good condition, commercial grade only)?
Power strips with circuit breaker, no household extension cords (no daisy chaining=surge protector plugged into surge protector)?
Electrical panels (unobstructed, breakers labeled, no open breaker slots)?
GFCI outlets in wet areas (within 3 feet of sinks)?
18" clearance from fire sprinkler heads?
24" clearance from ceiling
Alarm pull-stations and fire extinguishers clearly identified and unobstructed?
Egress routes are clear (halls, stairwells, and exits unobstructed) minimum 28" clearance?
Emergency and exit lights functioning?
Evacuation maps posted?
Fire extinguisher (tamper seals in place, tag <1 year old, 3 feet clearance)?
Fire extinguishers being inspected monthly with initials on the annual tag?
Work area adequately illuminated (no blown bulbs)?
Ventilation (adequate, free fro dust and fumes, vent grills clean)?
No signs of water leaks in ceiling tiles, floor, or other areas?
Storage areas are organized and clean (no items of floor)?
Emergency telephone numbers posted where they can be readily found?
Floor in good condition (no frayed carpet, loose tiles, slippery areas, etc.)?
No obvious slip, trip, or fall hazards?
No visible spills or utilization of wet floor signs for spills present?
First aid kit/AED with "no" expired products?
Recycling & trash bins orderly and not overflowing?
Rest rooms are clean and signature page present?
Hazardous chemical inventory up to date (within the past year)?
Secondary container (chemical containers) properly labeled?
Safety Data Sheets (SDSs) are current & available?
Proper training regarding chemicals before usage (ask an employee)?
All staff observed wearing ID badges with the pictures and names visible?
What does P-A-S-S stand for?
What does R-A-C-E stand for?
Where is the nearest fire pull station in your area?
Staff can locate the nearest fire extinguisher in your area?
Staff can identify the correct procedure in the event of a fire?
Staff has knowledge and uses Safety Data Sheets (SDSs)?
Staff can identify the number to call for security related incidents?
Proper PPE is worn while performing duties (review assessment for PPE)?
Sharps container not overfilled?
Proper disinfection wipes are being used (tuberculocidal for patient areas)?
Daily infection control logs completed for treatment rooms?
Sterilization logs complete and up to date? (Review sterilization logs to ensure all loads were accepted and biological ran at least weekly)
No patient items under sinks?
Blood and/or OPIM (other potentially infectious material) stored in proper refrigerator (labeled with Biohazard sticker)?
Negative pressure rooms checked off daily (NW)?
Other Recognized Hazards
Other Recognized Hazards found?
ATTENTION: DEPARTMENT MANAGER
As Department Manager I have reviewed the survey noting any areas of non-compliance. Corrective action has been taken and documented appropriately on this form. When applicable, employee retraining has been conducted to maintain future compliance in these areas.