Title Page
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Site conducted
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Conducted on
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Prepared by
Fire Extinguishers
- Add Fire Extinguisher
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What is the number of the Fire Extinguisher?
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Spill Kits
- Add Spill Kit
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What is the location of this kit?
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Is the spill kit unblocked, and easy to get to?
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Does the spill kit have the required items inclosed inside?
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What is missing?
Eye Wash
- Add Eye Wash Station
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What is the location of this station?
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Is this eye wash station plumbed?
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Is the eye wash station clear from obstructions?
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What is blocking it? Was it cleared?
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Is the eye wash station full charged?
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Are there any noticeable leaks or cracks that would allow the solution to leak out, or contaminates to get into the solution?
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Is the eye wash station "in date", not expired?
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What is the expiration date?
First Aid
- Add 1st Aid Kit
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What is the location of this kit?
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Is the kit stocked to meet min requirements?
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What is missing?
AED
- Add AED
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What is the location of this AED?
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Is the AED clear from obstruction?
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What was blocking the AED, and was it cleared?
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Is the AED battery "in date", not expired?
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What is the expiration date?
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Are the pads "in date", and not expired?
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What is the expiration date?
Closeout
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Other Concerns Identified?
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Completed By:
