• Business Name

  • Conducted on

Business Details

  • Inspection type:

  • Proprietor or Company Name

  • ABN

  • Business Trading Name

  • Business Premises Address

  • Business Postal Address (if different to above)

  • Business Contact Number

  • Business Contact Email

  • Business Representative Interviewed

Procedures Conducted on Premises

  • Type of procedure(s) undertaken at the premises

Cleanliness & Hygiene

  • Premises are clean and hygienic

  • Premises has a hand washing basin with a supply of clean, warm, potable water

  • Hand washing basin is equipped with soap and paper towels (or automatic hand dryer)

  • Hand washing basin is unobstructed and only used for hand washing

  • Premises has alcohol-based hand sanitiser available for use

  • Premises has a supply of single-use gloves, clean linens, and gowns or aprons appropriate for the procedures carried out

  • Is equipment used in skin penetration premises cleaned on the premises?

  • Is a separate sink available with clean, warm, potable water for the cleaning of equipment?

  • A waste disposal bin is available


  • Equipment is in good working order

  • Equipment is effectively cleaned and dried after use

  • Equipment is stored in a clean and dry condition

  • Are sharps in use at the premises?

  • Is a sharps bin available for sharps disposal that complies with either AS/NZS 4261-1994 (reusable) or AS/NZS 4031-1992 (non-reusable)?

  • Are needles used at the premises?

  • Is there an adequate supply of sterile, single-use needles?


  • Are reusable articles used to penetrate the skin in use at the premises?

  • Are reusable articles sterilised on-site or off-site?

  • An autoclave is in use for sterilising reusable articles?

  • The person undertaking the sterilisation is appropriately trained in the operation of the autoclave?

  • The autoclave is calbirated at least once every 12 months? (records available)

  • Are records of each sterilisation being kept for the last 12 months and are available for inspection?

  • Is the date and time the article was autoclaved recorded?

  • Is the length of time the article was autoclaved recorded?

  • Is the temperature and pressure level reached during autoclaving recorded?

  • Are records of the date on which articles were sent for sterilisation over the last 12 months being kept?

  • Are the contact details of the person or company who sterilised the articles recorded?

  • Are sterilisation reports being kept for the last 12 months and are available for inspection?

General Requirements for Procedures

  • Gloves are in use and changed after every procedure

  • A clean gown or apron is in use during the procedure (made of impermeable material if colonic lavage undertaken)

  • Needles are not re-used and are immediately disposed of after completing the procedure

  • Single-use sharps are immediately disposed of after completing the procedure

  • All articles are clean and sterilised, and stored in a sterile environment

Requirements for Specific Procedures

  • Is colonic lavage undertaken at the premises?

  • Is a toilet available for client use only and not the general public?

  • Is the procedure using a closed or open system?

  • The toilet is located close to the room in which the procedure is carried out

  • The toilet is located within the room and immediate area in which the procedure is carried out

  • Are inks or pigments in use at the premises?

  • Is the ink or pigment decanted into a single-use container for each procedure, applied with a single-use applicator, and then discarded after completing the procedure?

  • Is waxing undertaken at the premises?

  • Is the wax and spatula used in the procedure immediately disposed of after completing the procedure?


  • Further action required:

  • Business Representative Name

  • Business Representative Signature

  • Authorised Officer

  • Authorised Officer Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.