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