Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • Which clinic is being surveyed

Environmental Conditions/Infection Control

  • Are staff able to speak to the disinfectant dry time that is required before using the equipment or applying the table paper?

  • If a negative response to the above question, what was the issue identified.

  • Are sharps containers mounted/secured in clinic areas?

  • The sharps containers are not overfilled.

  • Are electrical pugs at floor level covered with child safety covers?

  • Are rooms with biohazard materials labeled and locked?

  • Does the procedure room have a dirty and clean side?


  • Are medications stored in a safe and secure location?

  • All medication is not expired.

  • Is the sample medication log kept up to date and completed per policy?

  • All single dose vials are discarded after use.

  • There are no opened multi-dose vials open without a BUD? (Note BUD 28 days after opened.)

  • There are no medications/hazardous liquids stored in bottom cupboards or drawers.

Emergency Response

  • O2 Tank full and in holder?

  • Is the appropriate ambu bag available based on population served in clinic?

  • Is the medication Box for common emergencies in clinic available?

Misc. Section

  • Are the OSHA/State Hiring Laws posted in the clinic?

  • Are PMs for equipment current per the MIFU?

  • Is the process for management of complaints posted in the clinic?

  • Are the PA/NP staff able to speak to the guidelines for management of health problems?

  • Is there a process to ensure the required number of NP/PA charts are reviewed per the organizations policy?


  • Is sterilization done in this clinic?

  • Are MIFU guidelines followed for proper cleaning of instruments?

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.