• Audit Title

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Appropriate storage of boxes and pt care items:<br> * Not directly on floor.<br> * 18" clearance from sprinkler head.<br> * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.<br> * Volume of combustible material is not stored in large quantity as to create a fire hazard.

  • Oxygen or other combustible compressed gas cylinders are stored properly:<br> * Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall)<br> * Limited to 12 E-cylinders per smoke compartment.<br> * Greater than 12 stored in a secured room.

  • Fire exits and hallways are cleared:<br> * Egress corridors must have 8ft clearance.<br> * Equipment in corridors must be actively accessed to be in use.

  • Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.

  • Fire extinguishers have been inspected monthly.

  • Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)

  • Fire doors are not blocked or propped and when closed there is positive latching.

  • Exit signs are illuminated.

  • Evacuation route posted & current.

  • Everyone has ID badges and worn appropriately:<br> * Staff and Visitors

  • Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

  • Floors, ceilings, walls, and other surfaces intact and free from holes.

  • Nurse call lights working.

  • Are there any alarms operating appropriately?


  • Greet the team with smiles and introductions.

  • Have a space designated for the team to conduct interviews and file reviews.

  • Promptly deliver materials required for review to the tracer team.

  • Any additional comments regarding positive or suboptimal issues observed during the tracer.

  • Surveyors Signature

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.