Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Life Safety

  • Will the fire alarm and/or detection system be inoperable or impaired? ( If yes Fill out interim Life Safety Measures )

  • Will emergency exits be obstructed? ( If yes fill out Interim Life Safety Measures )

  • Will repairs or maintenance be over occupied work areas? ( if yes fill out Interim Life Safety Measures )

  • Will normal traffic need to be rerouted? ( If yes fill out Interim Life Safety Measures )

  • Will their be work above the ceiling? ( If yes fill out Facilities Management Work Permit )

Infection Control

  • Will air quality be affected temperature,moisture,dust,required air changes? (If yes give description of what will be done to maintain air quality )

  • Will work area need to be concealed due to dust or infection control? ( If yes give description of how area will be concealed )

  • Will noise levels be affected in the area? ( If yes give description of what will be done to minimize noise levels )

Safety

  • Is personal protective equipment available in work area?

  • Has everyone around the work area been notified of work to be performed?

  • Will their be any Hot Work? ( If yes have Facilities Management fill out hot work permit )

  • Is fire extinguisher available in work area?

Risk Assessment Results

  • Select date

  • Add signature

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