• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Top surface and base of chair

  • Behind headrest and adjustment knob

  • Side panels

  • Under arm rest

Bracket table

  • Under tray and rim

  • Side handles

  • Top surface

Switch panel

  • Below switch panel and buttons

  • Bottom surface

  • Top surface

Hand piece Bracket

  • Outer surface

  • Hand piece cradle, buttons, and groves around buttons

  • Hand piece tubing and inner coupling grooves


  • Arm

  • Light cover and switch

  • Handles

Bench Tops

  • Clean area

  • Contaminated area

  • Clerical area

Suction Bracket

  • Outer surfaces

  • Underneath

  • Hand piece cradle, buttons, and inner rim of buttons

  • Hand piece tubing - wiping the entire tube


  • Inner bowl & upper ridge includes water- activator buttons

  • Spittoon filter and inner rim

X-ray Unit

  • Cone

  • Head

  • Arm

  • Outer trigger button and inner control pad

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.