Family/Practice Name:

Assessment Date:

Facility/Practice Address:

Facility/Practice Manager:

Person Preparing Report:

Contact Telephone number:

I. General Information

Description of Facility/Practice activities:

Description of Assessment Area:


Is property leased?

Is property owned?

Address & phone number of Law Enforcement Jurisdiction:

Operating Hours:

II. Building & Perimeter

Total number of perimeter entrances/exits:

Are all entrances/exits supervised?
If not, how are they controlled?

Perimeter fence(s) present?

If yes: Type:
Distance from Building:
Barbed Wire Top:

Roof openings or entries?
If yes, are they secured & how?

Floor grates, ventilation openings?
If yes, are they secured & how?

Adjacent occupancy?
If yes, describe:

Shrubs present?
If yes, are they in good condition & away from building?

Criminal activity in area?
If yes, describe:

Narcotics stored on site?
If yes, are they secured & how?

III. Vehicular Movement

Is employee parking within perimeter fence?

Do employees have access to vehicles during work hours?

Do vehicles have passes or decals?

IV. Lighting

Is perimeter lighting provided? If yes, is it adequate?

Is there an emergency lighting system within the facility?

Are all the exits sufficiently lighted?

Is external lighting in use during all night hours?

Is external lighting adequate for parking areas?

How is lighting external checked/maintained?

V. Locking Controls

Does the facility/practice have adequate control and records for all keys?

Is a master key system in use?

VI. Alarms

Does this facility utilize any security alarm devices?
Number of alarms?

Are alarms of central station type connected to law enforcement agency or outside monitoring service?

Is list of authorized personnel to "open & close" alarmed premises up to date?

Are local alarms used on exit doors?

If you have an alarm, do you have accompanying policy and procedure?

Is closed-circuit television utilized?

Is the CCTV recorded?

VII. Sensitive Populations/Areas

Does your facility treat or have any of the following sensitive populations/departments?


Behavioral Health?


Information Services?

Cash Office?

Other: (Describe)

VIII. Security Incidents

Has your facility suffered any security related events recently? (If yes, describe event, outcomes & corrective actions taken)

IX. Additional Comments

Any additional comments? (If yes, please comment)

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.