Monthly Eye Wash Inspection

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Eye Wash Station (Paint Line)

• Is access to equipment free & clear of tripping / slipping hazzards?

  Yes

  No

  N/A

• Does the water that drains in the waste container need to be emptied?

• Is the flow of water adequate?

  Yes

  No

  N/A

• Is the water clean and clear?

  Yes

  No

  N/A

• Do valves operate freely with no leaks?

  Yes

  No

  N/A

• Are the eye pieces and cover clean?

  Yes

  No

  N/A

• Are station identification signs in place?

  Yes

  No

  N/A

• Is an inspection tag / sticker attached to each station?

  Yes

  No

  N/A

• Additional Notes

Eye Wash Station (Welding)

• Is access to equipment free & clear of tripping / slipping hazzards?

  Yes

  No

  N/A

• Is the flow of water adequate?

  Yes

  No

  N/A

• Is the water clean and clear?

  Yes

  No

  N/A

• Do valves operate freely with no leaks?

  Yes

  No

  N/A

• Are the eye pieces and cover clean?

  Yes

  No

  N/A

• Are station identification signs in place?

  Yes

  No

  N/A

• Is an inspection tag / sticker attached to each station?

  Yes

  No

  N/A

• Additional Notes

Eye Wash Bottles (Paint Line Inside)

• Is the expiration date within the expiration period?

  Yes

  No

  N/A

• Are the eye wash bottles hanging upside down?

  Yes

  No

  N/A

• Is an inspection tag / sticker attached to each station?

  Yes

  No

  N/A

• Is the station clean?

  Yes

  No

  N/A

• Have the bottles been opened?

• Comments / Actions Needed

Eye Wash Bottles (Paint Line Close to door)

• Is the expiration date within the expiration period?

  Yes

  No

  N/A

• Are the eye wash bottles hanging upside down?

  Yes

  No

  N/A

• Is an inspection tag / sticker attached to each station?

  Yes

  No

  N/A

• Is the station clean?

  Yes

  No

  N/A

• Have the bottles been opened?

• Comments / Actions Needed

Eye Wash Bottles (Paint Line Outside)

• Is the expiration date within the expiration period?

  Yes

  No

  N/A

• Are the eye wash bottles hanging upside down?

  Yes

  No

  N/A

• Is an inspection tag / sticker attached to each station?

  Yes

  No

  N/A

• Is the station clean?

  Yes

  No

  N/A

• Have the bottles been opened?

• Comments / Actions Needed

• Inspector Signature

  Sign