Audit

Key:

0-2 Very Low Risk. No extraordinary actions required. Monitor

3-4 Low Risk. Educate. Enforce existing policies. Emphasize during EOC surveys. Monitor

5-9 Moderate Risk. Educate. Enforcen existing policies. Emphasize during EOC surveys. Monitor

10 > High Risk. Educate.Enforce/Develop effective policies. Emphasize during EOC surveys. Monitor

To get total multiply: Probability x Risk x Preparedness

Sharps/Needles Exposure

Probability

Risk

Preparedness

Total:

TB Exposure

Probability

Risk

Preparedness

Total:

Chemical Exposure

Probability

Risk

Preparedness

Total:

Lasers in Use

Probability

Risk

Preparedness

Total:

Blood & Body Fluid Exposure

Probability

Risk

Preparedness

Total:

X-ray Exposure

Probability

Risk

Preparedness

Total:

Falls

Probability

Risk

Preparedness

Total:

Ergonomics

Probability

Risk

Preparedness

Total:

Fire

Probability

Risk

Preparedness

Total:

ADA Violations

Probability

Risk

Preparedness

Total:

Assault

Probability

Risk

Preparedness

Total:

Theft

Probability

Risk

Preparedness

Total:

Suicide

Probability

Risk

Preparedness

Total:

HIPAA

Probability

Risk

Preparedness

Total:

Comments

Comments:

Print Your Name then Sign when completed
Forwarding Instructions

Please end form to Safety Compliance Office MS-04-142:

Phone # 254-724-3708, Fax # 254-724-4883

Email: CMORISSET@sw.org Keep a copy for your records

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.