Title Page

  • Memorial Hospital and Manor

  • Department / Area Inspected

  • Department Director Name and if they were present during the inspection.

  • Conducted on

  • Inspected By

Life Safety

  • Are exit doors and stairwells clear? Main, corridor, and stairwell exits cannot be blocked.

  • Are exit doors clearly marked "exit" and illuminated? Check for burned out bulbs.

  • Do fire doors latch properly? Close fire doors to see if they latch properly and see that there is no gap <1/8 inch in the middle.

  • Are corridors and passageways free of obstruction? The corridor can have mobile items (wheels on them) that are emergency needed items that are in use.

  • Are pull stations or fire extinguishers unobstructed? There must be nothing to obstruct access.

  • Are fire doors propped open/held open? Doorstops or homemade hold open devices are not allowed is in the area. Tape is not allowed over any strike plates.

  • Are storage rooms and equipment rooms free of clutter and unsafe conditions? Make sure items are not falling down or overstocked.

  • If Applicable Are Emergency Back-Up Lights in Working Condition.

  • Are all materials stored a minimum of 18" from the bottom of the sprinkler head?

  • Are sprinkler heads painted, dirty or rusting?

  • Are ceiling tiles where applicable, properly placed in the frames provided. No missing, broken or unleveled tiles?

  • Is the correct type of fire extinguisher available?

  • Are compressed gases stored properly? Compressed gases need to be chained to the wall or on a cart secured. Free standing bottles are not allowed.

  • Is Staff Aware of PASS and RACE

Safety Management

  • Is area free from evidence of smoking?

  • Are wet floors clearly marked to reduce tripping hazards? When floors are wet, does the staff put out wet floor signage?

  • Are the floors/ hallways in good condition?

  • Are ceiling tiles clean, stain free, and in good condition? Indicate where these bad tiles are located in the comments.

  • Are heavy items stored at low levels or mid levels in storage? Make sure the heavy items are stored at waist level or lower shelves.

  • Are general areas clean and free of clutter?

  • Are stair risers all the same height with no tripping hazards apparent?

  • Are stairwells properly lit to ensure safe evacuation when required. and are stairwell lights on emergency power?

  • Are handrails installed if yes are they installed at proper height? secured? and not damaged?

  • Are ladders used and stored appropriately?


  • Are any 2 pronged or damaged electrical cords in use?

  • Are electrical or cords keep away from walking paths?

  • Are there any unauthorized heaters or other mechanical equipment?

  • Are there any unauthorized extension cords?

  • Are residential lights being utilized for decoration purposes?

  • Are surge protectors piggybacked?

  • Are staff refrigerators, approved heaters and or microwaves in dedicated circuits.

  • Are there downtime procedures in place?

  • How is proper personnel notified when emergency operations are put into place?

Haz Mat & Waste

  • Are secondary chemical containers labeled with product name, hazard label and manufacturer? Indicate any chemical that is in a container other than the original container.

  • Are chemicals stored separately from patient care contact or other clean items?

  • Is the Hazardous Chemical Inventory adequate and available to all employees? The hazardous chemical inventory list will be in the SDS book within the department.

  • Are appropriate procedures, instructions, or directions available for obtaining SDS? There should be instructions within the department to access the SDS.

  • Are unapproved items stored under sinks?

  • Is biohazardous materials properly disposed of? Sharps containers and red bags?

  • Is there regular trash in the biohazardous waste containers?

  • Are any hazardous materials produced or disposed of in the department? (other than IMW)


  • Is staff's personal items properly secured? Check for purses, billfolds, money, keys, etc. left out for you to take.

  • Are all employees wearing their ID badges in plain view?

  • Are all mechanical, electrical, janitorial, communications rooms locked? Indicate which rooms are not locked.

  • Off-site Departments - Is staff aware of the 500#?

  • Is staff aware of emergency codes? and their role?

  • Is staff aware of the departments evacuation routes and assigned meeting place after evacuation?

  • How is security personnel contacted? Law Enforcement?

Medical Equipment

  • Does the medical equipment appear clean, and is equipment rusty or have chipped paint?

  • Are the castors in good condition, allowing equipment on wheels to roll properly?

  • Is all medical equipment accounted for?

  • Is there defective medical equipment in need of repair? If yes is it properly labeled?

  • Does staff know procedures for reporting defective equipment?

EOC Rounds Questions


  • Explain how to report an injury involving a staff member.


  • Explain your response to a Code Silver.

  • Explain your response to a Code Pink.

Life Safety

  • What does RACE stand for?

  • Where is the nearest fire alarm pull station in your location?

  • Where is your nearest fire extinguisher?


  • What is a Code Green?

  • Where are the MedSled Evacuation Sleds located?

Haz Mat and Waste

  • What goes into biohazard red bag waste?

Medical Equipment

  • How do you report a medical equipment problem?

  • Explain information found on the medical equipment sticker.


  • If the power in the hospital fails, explain how to locate outlets powered by the emergency generator.

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.