Renaissance Surgery Center Annual Emergency Lighting Test Egress Lights

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Where the breakers turned off and the generator started

  Yes

  No

  N/A

#1 Egress Light Front Door Common Area

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#2 Egress Light Left Hall Common Area

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#3 Egress Light Right Hand Hall Common Area

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#4 Egress Light Left Hand Hall Common Area

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#5 Lobby/ Waiting Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#6 Lobby/ Waiting Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#7 Front Office Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#8 Front Office Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#9 Pre-op Outside Business Office Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#10 Outside Room 117 Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#11 Pre-op at Waiting Egress Light

• Pass/ Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#12 Nurse Desk Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#13 Nurse Desk

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#14 Outside Treatment Room Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#15 O.R. Hall Outside Clean Instruments Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#16 O.R. Hall Outside Room 1 Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#17 O.R. Hall Outside Room 2 Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#18 O.R. Hall Back Door Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#19 Make Up Room Egress Light

• Pas/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#20 Outside Mechanical Room Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minxes)

• Corrective Action

#21 O.R. 1 Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#22 O.R. 1 Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#23 O.R. 2 Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#24 O.R. 2 Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

#25 O.R.1 Battery Egress Light

• Pass/fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#26 O.R. 2 Battery Egress Light

• Pass/fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#27 Treatment Room Battery Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#28 Mechanical Room Battery Egress Light

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

  Yes

  No

  N/A

• This signature certifies that I have reviewed and completed the inspection

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