MSAP - Monthly Refuge Station Check Sheet - J

• Audit Title:

• Area/Location/Cell Inspected:

• Area Supervisor:

• Conducted By:

• Conducted on:

  Date

Monthly Refuge Station Check Sheet

Add a Refuge Station

• Enter Refuge Station Location:

Eyewash Station:

• Is the eyewash station clean?

  Yes

  No

  N/A

• Is the eyewash solution expired? (Record Date)

  Yes

  No

  N/A

• This eyewash solution needs to be replaced.

• Record actions taken to replace eyewash solution.

• Has the eyewash station been used? (Check to see if the seal is broken)

  Yes

  No

  N/A

• This Eyewash Station needs to be replaced.

• Record actions taken to replace Eyewash Station.

First Aid Kit

• Is the first aid kit clean?

  Yes

  No

  N/A

• Has the first aid kit been used? (Check to see if the seal is broken)

  Yes

  No

  N/A

• Record actions taken to replace first aid kit.

• This first aid kit needs to be replaced.

Baskets

• Are the baskets clean?

  Yes

  No

  N/A

• Yes

  No

  N/A

• Do they contain the proper splints and back boards?

  Yes

  No

  N/A

Blankets

• Are the blankets clean?

  Yes

  No

  N/A

• Are the blankets folded and ready for use?

  Yes

  No

  N/A

Emergency Water

• Is the locked boxes have water?

  Yes

  No

  N/A

• Is it undamaged?

  Yes

  No

  N/A

• Are there any leaks?

  Yes

  No

  N/A

• Are the Emergency Procedures Present?

  Yes

  No

  N/A

• Are there blank report forms available?

  Yes

  No

  N/A

Emergency Procedures

• Is the top compartment stocked with Band-Aids?

  Yes

  No

  N/A

Phone Check

• When you pick up the phone, do you get a dial tone? Record the phone extension number.

  Yes

  No

  N/A

• Can you call out to security? To confirm phone is functioning properly. Record and ask security to read call display to ensure number and level are in sync.

  Yes

  No

  N/A

Acknowledgments

• Supervisor Signature:

  Sign

• General Foreman:

  Sign