Location, Time and Date

Location of Rounds

Time & Date

Are doors locked?

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Are all windows shut?

Intrusion Alarm Active?

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Are lights off?

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Areas safe and free from identified hazards that can injure staff, patients and/or visitors?

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Building and Grounds area free from Maintenance Issues or Repairs needed?

If no, was a work order submitted?

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Completed By
Signature of Officer Conducting Rounds

Printed Name

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.