New Safe Haven Inspection

• Location
  Address

• Prepared by

• Conducted on

  Date

• Other personnel attending the inspection

Access

• Proper signs posted and clearly identified "SAFE HAVEN"?

  Yes

  No

  N/A

• Are routes to the Safe Haven clearly identified?

  Yes

  No

  N/A

• Is access clearly illuminated?

  Yes

  No

  N/A

• Are the doors closed and is there a notice stating doors must be kept closed?

  Yes

  No

  N/A

Housekeeping

• Is approach to Safe haven clear and free of debris?

  Yes

  No

  N/A

• Is the air lock clean and orderly at the time of inspection?

  Yes

  No

  N/A

• Is the Safe Haven clean and free from litter and dirt?

  Yes

  No

  N/A

• Is the toilet in place and clean?

  Yes

  No

  N/A

• Is there adequate lighting in the safe Haven?

  Yes

  No

  N/A

• Is there adequate seating available and in good condition?

  Yes

  No

  N/A

Safety Equipment

• Is there a stretcher within 10 metres of the Safe Haven and in good condition?

  Yes

  No

  N/A

• General condition of the stretcher and accessories

  Safe

  At Risk

  N/A

• Is the first aid kit available within the Safe Haven and in good condition?

  Yes

  No

  N/A

• Is there an A.E.D. and Entonox available inside and have they been inspected?

  Yes

  No

  N/A

• Is there spare self-rescuers stored inside the safe haven and have they been inspected?

  Yes

  No

  N/A

• Emergency water available and within use by date?

  Safe

  At Risk

  N/A

• Temperature monitoring equipment in place?

  Yes

  No

  N/A

• Has the fresh air equipment been tested and is it functioning correctly?

  Yes

  No

  N/A

Communications

• Is there "Log In" book, note book and writing materials available?

  Yes

  No

  N/A

• Is the telephone working?

  Yes

  No

  N/A

• Is the DAC working?

  Yes

  No

  N/A

• Is the Safe Operating Procedure for the Refuge Station posted inside?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Is there an up to date copy of the Fire and Rescue Plan available inside the Safe haven?

  Yes

  No

  N/A

General comments

• Any issues identified, person responsible to rectify the issues and date issues to be rectified by.

• Is the Safe Haven safe for use?

  Yes

  No

  N/A

• Add signature

  Sign