Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

General Information

  • Do you have an OSHA Manual?

  • Is OSHA Manual up to date?

Ergonomic Plan

  • Customized ergonomic plan for office?

  • Plan accessible to all Employees? Posted?

  • Employees able to identify signs and symptoms of MDS's?

  • Employees know how to report signs and symptoms? Understand importance of reporting?

  • Employees trained in proper transfer techniques with patients?

  • Employees provided medical access, beyond first aid?

  • Employees provided work restriction protection for action trigger jobs?

  • Management and employee participation encouraged?

  • Training upon hire and every 3 years?

  • Report records kept for 3 years/HCP opinions kept for length of employment + 3 years?

  • Program evaluation performed to ensure risks are minimized and controlled?

  • Are employee work areas adequately lighted?

  • Is there adequate ventilation in employee work areas?

Written Exposure Control Plan

  • Does the employer have a written exposure control plan?

  • Exposure plan current?

  • Plan reviewed and updated at least annually?

  • Universal and standard precautions observed?

  • Engineering controls/work practice controls/ PPE?

  • Methods of compliance? (SOP) Schedules for implementing?

  • Exposure determination worksheets?

  • Management of exposure incidents? Immediate reporting of exposures and referrals?

  • Recordkeeping: Medical records, training, and incidents?

  • Plan accessible to all employees?


  • All employees provided training?

  • Training provided prior to performing duties during normal business hours?

  • Disease control training updated annually for Hep B and C, HIV, TB and Anthrax?

  • Exposure control and Universal Precautions updated annually?

  • Provided training at an appropriate level of comprehension and interactive?

  • Training records kept for a minimum of 3 years?

Confidential Medical Files (Kept term of employment + 30 years)

  • Medical Reports?

  • Vaccination History?

  • Informed Consent(s)?

  • Informed Refusal(s)/Condition of Employment?

  • Exposure determination?

  • Incident reports?

  • Post Exposure follow up?

  • Written opinion(s)?

Personal Protective Equipment

  • PPE Provided to all employees? (gloves, masks, apparel - all in appropriate sizes)

  • PPE designed with knee length, long sleeves, and crewneck to protect legs, arms, and neck?

  • Gloves worn and changed after each patient?

  • Masks worn and changed after providing care to potentially infectious/contagious patient?

  • Protective eyewear/shields worn and disinfected after each patient?

  • Lab coats and/or gowns worn and changed when visibly soiled or when leaving treatment areas?

  • Employees prohibited from home laundering gowns?

  • Synthetic gloves provided to those who have latex sensitivity?

  • All employees offered Hepatitis vaccination free of charge and within 10 days of task assignment? Vaccine offered only after risks and benefits have been explained?

  • If vaccination declined, employee sign a vaccine declination form? Aware that they can accept at a later date?

  • Hand hygiene policies been reviewed?


  • Soiled laundry placed in marked bags or containers?

  • Employees DO NOT TAKE contaminated laundry home?

  • Employees minimize handling and wear appropriate PPE when handling?

Posters and Signs Appropriately Displayed

  • Safety and Health protection on the job? (Employee rights OSHA 2203 Language poster (OSHA 3165))?

  • Notice of Workers Compensation?

  • Emergency Evacuation Plan?

  • Form 200, if 11 employee or more

  • Emergency telephone numbers/qualified first aid providers?

  • Illuminated Exit and "Not An Exit" signs posted?

  • Biohazard Symbol

  • Eyewash station location?

  • Housekeeping schedule posted?


  • Engineering sharps injury protection (self sheathing needles)?

  • Have Employees been allowed to evaluate engineered sharp protection devices? Documented?

  • If needles are recapped, do employees use self-sheathing device or 1 handed scoop technique?

  • Exposed individuals/source patient tested as soon as feasible for HIV, HBV, and HCV?

  • Containers readily accessible in the area of use? Containerized immediately after use?

  • Containers have a closeable lid, and are puncture resistant, labeled, and leak proof?

  • Containers prohibit two handed removal, not allowed to be overfilled?

  • Employees prohibited from using two handed recapping?

  • Contaminated needles and sharps prohibited from being bent?

  • Filled containers transported by licensed recycler?

  • Work Place Controls employed to reduce risks when handling sharps?

Waste/Waste Segregation

  • Regulated medical waste in closeable, leak proof biohazard labeled containers/pick up by licensed recycler?

  • Biohazard waste identified with biohazard symbol?

  • Have employees been trained on the office biohazard waste plan?

  • Infectious waste hauled by certified waste hauler? Manifest records kept on file for 7 years?

  • Does business owner have EPA# for small generator? (800-618-6942)

  • Spent hazardous waste (cannot go down drain) picked up by licensed recycler?

  • Expired pharmaceuticals containerized and disposed of properly?

  • Office treating their own waste? EPA # for treating on site? Records kept?

  • Instruments sterilized or disinfected according to CDC and/or state requirements?

  • Is biological monitoring performed weekly to ensure each autoclave or other mechanical sterilizers are functioning properly?

  • Are appropriate disinfectants used for disinfecting surfaces?

  • Employees received annual training on bloodborne pathogens and how to comply with the facility's plans to reduce the risk of infection? Documentation of those trainings?

  • Does the training include methods of transmission of bloodborne pathogens and the symptoms of HIV and Heptitis?

  • Is medical waste found in solid waste containers?

  • Is solid waste found in RMW container and/or sharps container?

Hazard Communication

  • Written program customized and reviewed/updated annually? Done when new products are introduced?

  • Have employees been trained on your Hazard Communication plan?

  • Do employees know where SDS information is located and understand how to read a SDS?

  • Does program include description of how to read the label and use SDS sheets?

  • SDS sheets on file with inventory control list? Paper? Electronic?

  • Keeping Master List for 30 years - including those that are no longer used?

  • Request letters to Manufacturers for missing SDS's on file?

  • All products labeled at the point of use have original labels?

  • All transferred products re-labeled with product name, chemical ID, and appropriate hazard?

  • Are labels on secondary containers readable?

  • All employees have read, reviewed, and signed off on each SDS?

  • Is there a Master List of Hazardous Chemicals set up and maintained?

  • Are chemicals stored properly?

  • Have chemical containers been inspected for leaks?

  • Employees understand emergency spill procedures? Spill kit maintained?

  • All employees know how to use eyewash station?

Medical Emergencies, Safety, and First Aid

  • Is at least one person on each shift trained in first aid and CPR?

  • Do all staff members know how to immediately report occupational exposure to blood or other OPIM?

  • Does the employer or designated manager fill out an exposure incident form?

  • Does the incident report contain: Date, time and route of exposure, circumstances, and severity of exposure?

  • All employees trained in Occupational Injury and Illness Prevention? Records maintained?

  • Qualified safety controller identified?

  • Safety Committee established? Members identified?

  • Monthly meetings held? Meeting minutes?

  • Accident file established and maintained?

  • Periodic inspection of facility (first aid, fire, electrical, and evacuation)?

  • First Aid training provided?

  • First Aid supplies keot stocked and replenished periodically?

  • Eyewash station within 25 feet or 15 seconds without obstruction (door, furniture, etc)?

  • Eyewash station has proper signage? Sign designate location?

  • Eyewash station functioning properly? (Monthly Bump Test)

  • Have employees been trained on how to use the eyewash station?

  • Does eyewash station deliver cold water to avoid thermal injury to the eyes?

  • Emergency facilities within 15 minutes or qualified person available?

  • Proper lifting procedures? (SEE ERGONOMIC PLAN)

  • Are there any trip and fall hazards?

  • Food and drink held or consumed in areas where they could be contaminated?


  • Multiple plug adapters prohibited?

  • All electrical devices with a three prong plug grounded?

  • All electrical outlets within 6 feet of sink or water on a grounded fault interpreter (GFI) circuit?

  • Electrical cords in good condition?

  • Circuit breakers properly marked?

  • Do employees know where circuit breakers are and how to cut power?


  • Employees aware of fire hazards of materials?

  • Fire alarm on premises?

  • Fire extinguishers inspected, recharged, and accessible 3 feet from floor?

  • Emergency escape procedures/evacuation plan?

  • Floor plan with method of egress? Periodic mock fire drills?

  • Exit signs/Not An Exit sign (where applicable): front, side, rear

  • Are all exit signs properly marked?

  • Are exit paths clear of obstructions, both inside and out?

  • Maximum occupancy?

  • All exit doors unlocked so emergency egress does not require a key?

  • Have you reviewed emergency escape procedures and route assignments, such as floor plans, workplace maps, and safe refuge area?

  • Are employees aware of fire and emergency plan(s)?

  • Fire extinguishers mounted at eye level?

General Housekeeping, Storage, and Walking Surfaces

  • Instrument processing center(s) kept in clean, uncluttered, and sanitary condition?

  • Imaging center(s) kept in clean, uncluttered, and sanitary condition?

  • Treatment rooms kept in clean, uncluttered, and sanitary condition?

  • Laser/surgical suites kept in clean, uncluttered, and sanitary condition?

  • Storage rooms kept in clean, uncluttered, and sanitary condition?

  • Walkways kept in clean, uncluttered, and sanitary condition?

  • Staff lounge kept in clean, uncluttered, and sanitary condition?

  • Business Office/Private offices kept in clean, uncluttered, and sanitary condition?

  • Food and drinks consumed outside of exposure area?

  • Walking and working surfaces are dry?

  • Waling and working surfaces are slip resistant?

  • Articles stored on shelves stored so they can't fall on employees?

  • Areas under sinks and trash areas clean and orderly?


  • Nitrous Oxide use?

  • Air Quality control?

  • Is all equipment given regularly scheduled, routine maintenance to ensure it is functioning properly? Records of maintenance completed?

  • Repair records of all equipment maintained in office?


  • Equipment in good and safe condition with guards and shields?

  • Are safety shields in place to protect against projectile debris?

  • Nitrous Oxide/Oxygen stored in a manner to prevent tipping? Chained?

  • Are empty and unused compress cylinders capped and properly labeled?

Laser Safety


  • Lasers are classified appropriately (2, 3R, 3B, 4)

  • Standard operating procedures available?

  • Alignment procedures are available?

  • Viewing cards are used for alignment?

  • Laser users attended appropriate training?

  • Lasers are included in inventory?

Labeling and Posting

  • Certification Label Present?

  • Class designation and appropriate warning label present?

  • Radiation output information on label?

  • Aperture label present?

  • Appropriate label/sign at entrance to laser area?

  • Warning posted for invisible radiation?

Control Measures

  • Protective housing present and in good condition?

  • Beam attenuator present?

  • Laser table below eye level?

  • Beam is enclosed as much as possible?

  • Beam not directed towards door or window?

  • Beams are terminated with fire resistant beam stops?

  • Surfaces minimize specular reflections?

  • Controls are located so that the operator is not exposed to beam hazards?

Personal Protective Equipment

  • Eye protection is appropriate for wavelength?

  • Eye protection has adequate OD?

  • Warning/indicator lights can be seen through protective filters?

Class 3B and 4 Lasers

  • Interlocks on protective housing?

  • Service access panel present?

  • Limited access to spectators?

  • Nominal hazard zone determined?

  • Operators do not wear watches and reflective jewelry while laser is operating?<br>

  • Viewing portals present where MPE is exceeded?

Class 4 Lasers

  • Failsafe interlocks at entry to controlled area?

  • Area restricted to authorized personnel?

  • Laser may be fired remotely?

  • Laser may be fired remotely?

  • If present, curtains are fire-resistant?

  • Area designed to allow rapid emergency egress?

  • Pulsed- interlocks designed to prevent firing of the laser by dumping the stored energy into a dummy load?

  • CW- interlocks designed to turn off power supply or interrupt the beam by means of shutters?

  • Operators know not to wear ties around the laser?

Non Beam Hazards

  • High voltage equipment appropriately grounded?

  • High voltage equipment located away from wet surfaces or water sources?

  • High voltage warning label in place?

  • Compressed gases secured?

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.