MONTHLY EYEWASH INSPECTION - I7G

• Site Name

  Select

• Inspection Date/Time

  Date

• Inspector Name

• Location of Eyewash Station
  Address

• Eyewash Station ID Number

OBSTRUCTIONS

• Is the eyewash station accessible within 10 seconds, or roughly 55 feet?

  Yes

  No

  N/A

• Are there any pallets, ladders, buckets, boxes, material, or any other potential hazards obstructing the path to the eyewash station?

  Yes

  No

  N/A

• Is the eyewash at the same level as the hazard? (Is there a step up to access the eyewash equipment)

  Yes

  No

  N/A

LIGHTING AND SIGNAGE

• Is the area well lit?

  Yes

  No

  N/A

• Are light bulbs and light fixtures in working condition?

  Yes

  No

  N/A

• Is the eyewash safety sign highly visible?

  Yes

  No

  N/A

EXTERNAL CONDITION OF EYEWASH STATION

• Are dust caps and/or dust covers in place?

  Yes

  No

  N/A

• Is water leaking or moisture present?

  Yes

  No

  N/A

• Is there damage or cracks to the unit?

  Yes

  No

  N/A

• Is there any dirt or debris present?

  Yes

  No

  N/A

• Is the pull rod, push flag, or other parts of the unit in a functional and usable state?

  Yes

  No

  N/A

WORKING CONDITION OF EYEWASH STATION

• Can eyewash station deliver a constant flow for 15 minutes, hands-free, to both eyes?

  Yes

  No

  N/A

• Can eyewash station be activated in 1 second or less with foot or one-handed control?

  Yes

  No

  N/A

• Does the flow of the eyewash station remove the eyepiece covers?

  Yes

  No

  N/A

WORKING CONDITION OF EYEWASH STATION: PORTABLE STATION

• Is the fluid at the proper fill line?

  Yes

  No

  N/A

• When was the last time the station has been completely drained, rinsed, and replaced with new solution?

  Date

• Does the eyewash station have the proper fluid? (a bacteria preventative to help keep the water fresh)

  Yes

  No

  N/A

• Is the height of fluid flow pattern between 33-53 inches from the surface the user stands on?

  Yes

  No

  N/A

• Is the eyewash station at least 0.6 inches from the wall?

  Yes

  No

  N/A

WORKING CONDITION OF EYEWASH STATION: PLUMBED STATION

• Does the water appear to be dirty or cloudy?

  Yes

  No

  N/A

• Is water temperature "tepid" (60-100 degrees F)?

  Yes

  No

  N/A

• Is the water pressure and flow constant? (not erratic)

  Yes

  No

  N/A

QUALITY CONTROL

• Has the check card been initialed and dated?

  Yes

  No

  N/A