Renaissance Surgery Center Annual Emergency Lighting Test Exit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Where The Breakers Turned Off and the Generator Started

  Yes

  No

  N/A

#1 Front Lobby/Waiting Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#2 Front Office Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#3 Front Office Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#4 Recovery Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#5 Door At Supply Hall Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#6 Door In Back Hall Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#7 O.R. Hall Double Door Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time(in minutes)

• Corrective Action

#8 O.R. #1 In Hall Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#9 O.R Hall Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#10 Back Door O.R. Hall Exit

• Pass/ Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#1 Common Area Front Door Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#2 Common Area Left Hall Exit

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#3 Common Area Right Hall

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

#4 Common Area Bach Hall

• Pass/Fail

  Pass

  Fail

  N/A

• Time (in minutes)

• Corrective Action

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

  Sign