Title Page

  • SAF

  • Practice Name

  • Location
  • Audit Title

  • Conducted on

  • Prepared by

  • Maine Medical Center’s Safety-Emergency Management (S-EM) Department visited your practice and a Safety Survey was conducted utilizing the Maine Medical Center Safety - Emergency Management Department’s Survey Tool for Business Occupancy to cover the following topics: General safety, staff knowledge, life safety, electrical safety, medical equipment, hazardous materials & waste, emergency management, security & grounds, and utility management. The following is a list of the S-EM Department’s findings and recommendations. A Corrective Action Plan must be completed by the Practice Manager and returned to the S-EM Department (Tammy Batchelder) and MMP Operations (Tricia Jordan) within 30 days. If you have any additional questions, concerns or need further clarification on any of the recommendations, please feel free to contact the Safety-Emergency Management Department at 207-662-2513.

  • Practice Name

  • Date of Survey

General Safety / Healthy Environment

  • Environment is clean, odorless, well lit, and trash is not overflowing.

  • No evidence of water damage is visible, ceiling tiles are not stained. 

  • Ceiling tiles are not broken or missing.

  • There are no tripping hazards. 

  • Patient Rest Rooms have working emergency pull cords that are 8" off the floor 

  • Alcohol based hand rub in appropriate locations mounted 48" from the floor, spaced 48" apart and at least 1" from potential ignition sources. 

  • Under sink storage is not being utilized. 

  • Additional staff safety concerns have been addressed

Staff Knowledge - All Topics

  • Staff able to verbalize evacuation/relocation plan including location of at least two separate exit routes, including assembly location. 

  • Staff can locate at least two fire extinguishers and fire alarm pull stations. 

  • Staff able to verbalize emergency Codes (Red, Pink, Purple, Green, Blue, Grey, Silver, White, Orange, Yellow & Triage) and able to verbalize RACE and PASS. 

  • Staff knows how to identify medical equipment in need of inspection or repair. 

  • Staff knows where and how to access SDS online. 

  • Staff know how to report an incident resulting in harm to a patient, visitor, co-worker, or themselves. (R.L Solutions - home page intranet - Incident Reporting) 

Life Safety - Compartmentation and Egress

  • Fire Rated walls are in good repair with all penetrations fire stopped (Enclosures of stairs, shafts/chases, mechanical/electrical, soiled linen, trash and storage rooms)

  • Penetrations of floor/ceiling assemblies are smoke resistive (cabling, plumbing, HVAC ducts). Fire stopping is recommended. 

  • Corridor walls are smoke resistive. 

  • Ordinary hazard mechanical or storage rooms in sprinkler protected building has smoke resistive walls with self closing positive latching door.

  • Mechanical or storage rooms in non sprinkler protected building has 1 hour rated enclosure with 3/4 hour self closing positive latching fire door.

  • Stairway landings are free of storage. 

  • Storage in corridors does not impede egress (36" min. corridor width). 

  • No doors are propped open and fire doors self close and positively latch. 

  • All EXIT signs are in working condition with at least two light sources and are properly placed. 

  • Egress to public way is maintained in Winter with snow and ice conditions.

  • Emergency lighting is present and functional (Battery operated emergency lighting, 10 seconds)

  • Elevator emergency phone is functional.

Life Safety - Detection / Suppression / Decorations / Furnishings

  • Fire alarm pull stations, electrical panels, fire hose connections and Med gas controls are unobstructed.

  • Emergency Strobe lights are present in all patient care areas including public access conference rooms, exam rooms, waiting areas and public restrooms. 

  • Extinguishers are present in cabinets, on brackets, etc. Have been inspected monthly / annually and appropriate for the hazards present. 

  • 18" vertical clearance from sprinkler heads is maintained.

  • Storage is 8" off floor and bottom shelf is solid. (no outer card board boxes on shelving).

  • Combustible decorations and postings are protected behind glass, Lexan or Plexiglas. Temporary postings (30 days or less) are laminated or are made of fire retardant materials.

  • If there is a Life Safety Code deficiency has an ILSM assessment been done?

  • Additional staff Life Safety concerns have been addressed. (ie no evidence of smoking on grounds)

Electrical Safety

  • Extension cords/power taps are used temporarily only in construction areas or for maintenance activity.

  • Electrical circuit panels have 36" clearance, all circuits identified, panels locked or in locked rooms. 

  • Surge suppressor cords are not interconnected together.

  • Space heaters are not used. (Permissible by medical clearance only) 

  • Only Commercial Grade heat producing appliances are in use. Examples: coffee makers, electric tea kettles, microwave ovens, toasters.

  • Additional staff electrical safety concerns have been addressed.

Medical Equipment

  • Medical equipment has a current inspection date.

  • Equipment is clean and in proper working order.

  • Additional staff medical equipment concerns have been addressed.

Hazardous Materials & Wastes

  • Proper containers are present for segregation of Hazardous, Universal and Bio-hazardous wastes as needed.

  • Proper eye wash stations and signage are present and logs are being done weekly.

  • There is proper segregation of "clean" and "potentially contaminated" areas (chemical, nuclear, biological and food and drink).

  • Oxygen storage rooms are identified by signage.

  • Oxygen cylinders are in holder and not laying or standing on floor. (Up to 12 E cylinders or 1 H cylinders in mixed use storage)

  • Housekeeping chemical containers are properly labeled. 

  • Sharps containers less then 3/4 full and clear access.

  • Are critical storage areas locked (pyxis, med rooms, biohazard rooms & mini-bins).

  • Refrigerators are property labeled for allowed use. 

  • Spill kits are appropriate for the risks that are present.

  • Additional staff HAZMAT concerns have been addressed.

Emergency Management

  • Additional staff EM concerns have been addressed.


  • All employees are wearing and have visible ID badges.

  • Visitors in sensitive areas are wearing proper ID (i.e. Guests & Contractors)

  • Barriers, locks and security hardware are functioning properly. (This would be a brief check, including windows, roof hatches and open core stairs)

  • Security system(s), if any, are operational per staff 

  • Additional staff security concerns have been addressed (ie parking lot lighting and call boxes).

Utility Management

  • Additional staff UM concerns have been addressed.


  • Entrance is ADA accessible and 18" clear floor space to latch side.

  • Handicap parking is present

  • Are there ADA accessible restrooms?

Additional comments

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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.