Safety Inspection or EOC Checklist for Medical, Dental, and Veterinarian Clinics

• Document No.

• Safety or EOC Inspection

• Client / Site

• Conducted on

  Date

• Prepared by:

• Location
  Address

• # Personnel Assigned

General Safety

• Are walking-working surfaces kept in a clean, orderly, sanitary condition and maintained free of hazards such as sharp or protruding objects, loose boards, corrosion, leaks, spills, snow, and ice. 29 CFR 1910.22(a)(1) and (a)(3); EC.02.01.01 EP 6

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• All places of employment shall be kept clean to the extent that the nature of the work allows. CFR 1910.141(a)(3)(i); EC.02.01.01 EP 3<br>

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• All places of employment, passageways, storerooms, service rooms and walking-working surfaces are kept in a clean, orderly, and sanitary condition. 29 CFR 1910.22(a)(1); EC.02.01.01 EP 3<br>

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• All walking-working surfaces are inspected, regularly and as necessary, and maintained in a safe condition? 29 CFR 1910.22(d)(1); EC.02.01.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are staff refrigerators clean and food products not expired? 29 CFR 1910.141(g)(2); EC.02.01.01 EP 3<br>Specific to expiration dating and discarding unused food, organizations are expected to comply with the product manufacturer's guidelines for safe storage as well as applicable law/regulation that may be defined by your local authority having jurisdiction (i.e. local or state health department, etc.).

  Yes

  No

  N/A

• Are spaces underneath sinks kept clear of stored items? IC.02.02.01 EP 1

  Yes

  No

  N/A

• No food or drinks in patient care areas, nurse's stations or in work areas where there is a reasonable likelihood of occupational exposure. 29 CFR 1910.1030(d)(2)(ix)<br>

  Yes

  No

  N/A

• Are ice machines cleaned and schedule of cleaning posted? IC.02.02.01 EP 1

  Yes

  No

  N/A

• Are combustible materials stored appropriately and not near a heat source? EC.02.01.01 EP 3

  Yes

  No

  N/A

• Are patient rooms clean? EC.02.06.01 EP 20

  Yes

  No

  N/A

• Are treatment rooms (space clean, unobstructed, and personal belongings secured)? EC.02.06.01 EP 1

  Yes

  No

  N/A

• Is lighting suitable for patient treatment and care? EC.02.06.01 EP 11

  Yes

  No

  N/A

Electrical Safety

• Are portable cord and plug-connected equipment and flexible cord sets (extension cords) visually inspected for external defects (such as loose parts, deformed and missing pins, or damage to outer jacket or insulation) before use on any shift, and for evidence of possible internal damage (such as pinched or crushed outer jacket)? Cord and plug-connected equipment and flexible cord sets (extension cords) which remain connected once they are put in place and are not exposed to damage need not be visually inspected until they are relocated. DA PAM 385-26, paragraph 2-4x; NFPA 70; EC.02.01010 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are all possible shock hazards eliminated? 29 CFR 1910.303(b)(1); EC.02.01.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are arcing parts of electric equipment that in ordinary operation produce arcs, sparks, flames, or molten metal enclosed or separated and isolated from all combustible material? 29 CFR 1910.303(d)

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are receptacle faceplates installed so that they completely cover the opening and seat against the mounting surface? DA PAM 385-26, paragraph 2-5d; EC.02.01.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Do electrical panels have proper clearance around (36 in (.9 m) (depth), 30 in (.76 m) (width) and 6.5 ft (1.98 m) (height) in most situations (see NFPA 70 (NEC), Article 110 for details) in front of panel door) and locate it so that it is not exposed to physical damage. DA PAM 385-26, paragraph 5-6; EC.02.01.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment? 29 CFR 1910.303(b)(7)(i); EC.02.01.01 EP 3<br>

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are flexible cords (extension cords) and cables not used as a substitute for the fixed wiring of a structure or ran through holes in walls, ceilings, floors, run through doorways, windows, or similar openings? 29 CFR 1910.305(g)(1)(iv)(A); 29 CFR1910.305(g)(1)(iv)(B); 29 CFR 1910.305(g)(1)(iv)(C); EC.02.01.01 EP 3<br>

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Do adapters if used, maintain continuity of equipment grounding when connected? 29 CFR 1910.334(a)(3)(iii); EC.02.01.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are Ground Fault Circuit Interrupters (GFCI) outlets in appropriate locations (e.g. within six feet of wet locations, all bathrooms, sinks, etc.)? DA PAM 385-26, paragraph 2-6a; EC.02.01.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• There are no stringing of extension cords (daisy chain or splitting) or going from one cord to several (tree branching) unless approved by the local safety authority? DA PAM 385-26, paragraph 2-4n.

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are childproof electrical outlet covers in place, where required?

  Yes

  No

  N/A

• Are portable electric heaters not in-use/or authorized for use in the area? EC.02.01.01 EP 3

  Yes

  No

  N/A

Fire Safety

• Are fire doors kept shut and not propped open? NFPA 101; EC.02.03.01 EP 1

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are items stored kept a distance of 18 inches clearance of sprinklers or 24 inches in non-sprinkler locations from the ceiling? NFPA 13; LS.02.01.30 EP 6; EC.02.03.01 EP 4

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are storage areas that are fire protected by either an automatic sprinkler system or 1-hour fire resistant construction with positive latching? NFPA 101; LS.02.01.30 EP 2

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are emergency exit signs operate properly (e.g. illuminated and tested)? NFPA 101

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are emergency exit signs clearly indicated and visible from all directions? NFPA 101; EC.02.03.01 EP 27

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are exit access, routes, exits, and exit discharge clear of obstructions? 29 CFR 1910.36(g)(1); 29 CFR 1910.36(g)(2); 29 CFR 1910.36(d)(2); 29 CFR 1910.36(c)(1); LS.02.01.20 EP 13

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are portable fire extinguishers mounted, located and readily accessible to employees without subjecting the employees to possible injury? 29 CFR 1910.157(c)(1); LS.02.01.20 EP 27;

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are portable extinguishers visually inspected monthly and annotated on the fire extinguisher tag or other appropriate means? 29 CFR 1910.157(e)(2); EC.02.03.05 EP 15/16<br>

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Does the employer provide an educational program to familiarize employees with the general principles of fire extinguisher use and the hazards involved with incipient stage of fire-fighting upon initial employment and at least annually thereafter? 29 CFR 1910.157(g)(1) and (2); EC.02.03.01 EP 10<br>

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Is the fire emergency number readily available? EC.02.03.01 EP 10

  Yes

  No

  N/A

• Are flammable liquids and oxygen cylinders stored properly? NFPA 99; SB-8-75-S11; EC.02.03.01 EP 1

  Yes

  No

  N/A

• Are doors for stairwells, storage rooms, locker rooms, soiled linen rooms, and trash collection rooms kept closed at all times? LS.02.01.10 EP 5

  Yes

  No

  N/A

• Are items not stored on the floor in patient care areas? IC.02.02.01; LS.02.01.70 EP 4

  Yes

  No

  N/A

• Are manual fire alarm stations visually clear and free of obstructions? LS.02.01.70 EP 4

  Yes

  No

  N/A

• Are ceiling tiles in-place, free of stains, and free of damage?

  Yes

  No

  N/A

• Are waste paper receptacles made of noncombustible material? LS.02.01.70 EP 4

  Yes

  No

  N/A

• Does paper on the walls cover less than 10% of the wall space? LS.02.01.70 EP 4

  Yes

  No

  N/A

• Decorations meet applicable standards? LS.02.01.70 EP4

  Yes

  No

  N/A

• Are curtains fire-retardant? LS.02.01.70 EP 4

  Yes

  No

  N/A

• Is the unit's fire plan updated annually? Do staff members review the fire plan and are aware of the exit routes and assembly area?

  Yes

  No

  N/A

• Can personnel describe or demonstrate their specific roles and responsibilities in preparing for a building evacuation?

  Yes

  No

  N/A

• Does the unit have any ILSM in-place? (If applicable) EC.02.06.05 EP 2 & 3

  Yes

  No

  N/A

• Did the unit complete an ICRA and Risk Assessment prior to construction beginning? (If applicable)

  Yes

  No

  N/A

• Can personnel describe or demonstrate the location and proper use of equipment for evacuating or transporting patients to refuge areas?

  Yes

  No

  N/A

• Trash containers or solid linen containers are not greater than 35 gallons within a 64 square foot area? LS.02.01.70 EP 2

  Yes

  No

  N/A

• When was the last fire drill conducted? EC.02.03.03 EP 2

  Date

• Date of last fire drill within the last 12 months? EC.02.03.03 EP 2

• Was an AAR completed for the fire drill?

Medicine and Sharps Storage

• Are storage containers locked when unattended? EC.02.01.01 EP 8

  Yes

  No

  N/A

• Are syringes and needles controlled to prevent public access? EC.02.01.01 EP 8

  Yes

  No

  N/A

• Are disinfectants or cleaners not stored with medications? EC.02.01.01 EP 3

  Yes

  No

  N/A

• Is the medication room locked/secured? EC.02.01.01 EP 8

  Yes

  No

  N/A

Storage and Handling of Compressed Gases

• Are compressed gases stored not exceeding the allowable quantity, properly secured, and segregated 20 feet from combustible materials in non-sprinkler areas or 5 feet in sprinkler areas? NFPA 99; SB-8-75-S11

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are O2 cylinders tagged properly empty/full/warning tag and do not oil tag? SB-8-75-S11; EC.02.01.01 EP 1 & 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are O2 cylinders bear proof of oxygen purity testing checks upon receipt? SB 8-75-S11; EC.02.01.01 EP 1& 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are compressed gas tanks properly labeled and secured to prevent them from falling or tipping over? Are the caps on when regulators are not in-place (no cylinders are to be stored with regulators attached). 29 CFR 1910.253(b)(2(ii) and (iv)

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are oxygen cylinders stored correctly? Are empty and full containers physically separated? In-use cylinders are not stored with full cylinders?

  Yes

  No

  N/A

Hazardous Communication

• Does the unit have a HAZCOM site-specific program with training? 29 CFR 1910.1200

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Are the hazardous chemical inventories current and all Safety Data Sheets available for each hazardous chemical? 29 CFR 1910.1200(g)(1) and (g)(1)(i); EC.02.02.01 EP 1 and 11

  Safe

  At Risk

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Is personal protective equipment (PPE) available? 29 CFR 1910.132(a); EC.02.02.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Is PPE properly stored? 29 CFR 1910.132(f0(2)(v); EC.02.02.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Has the staff been trained on donning, doffing, storage, disposal, and limitations of PPE? 29 CFR 1910.132(f)(2)(iii); EC.02.02.01 EP 3

  Yes

  No

  N/A

• Risk Assessment Code

  Select 1(I,A) 1(I,B) 1(II,A) 2(III,A) 2(I,C) 2(II,B) 3(III,B) 3(II,C) 4(I,D) 4(II,D) 4(III,C) 4(IV,A) 4(IV,B) 5(III,D) 5(IV,D) 5(IV,C)

  • 1(I,A)
  • 1(I,B)
  • 1(II,A)
  • 2(III,A)
  • 2(I,C)
  • 2(II,B)
  • 3(III,B)
  • 3(II,C)
  • 4(I,D)
  • 4(II,D)
  • 4(III,C)
  • 4(IV,A)
  • 4(IV,B)
  • 5(III,D)
  • 5(IV,D)
  • 5(IV,C)

• Isolated/Facility-wide Issue

• Corrective Action Plan

• Responsible Party

• Estimated Completion Date

  Date

• Does the HAZCOM representative on orders and have a training certificate?

  Yes

  No

  N/A

• Are all chemical labels in English? 29 CFR 1910.1200(f)(2); EC.02.02.01 EP2

  Yes

  No

  N/A

• Are chemicals separated by hazard type? EC.02.02.01 EP 35

  Yes

  No

  N/A

• Are labels properly affixed to incoming containers of hazardous materials? 29 CFR 1910.1200(f)(9); EC.02.02.01 EP 12

  Yes

  No

  N/A

• Are flammable storage cabinets properly marked with "Flammable - Keep Fire Away"? 29 CFR 1910.106(d)(3)(ii); EC.02.02.01 EP 12

  Yes

  No

  N/A

• Are flammable storage cabinets only used for flammables? EC.02.02.01 EP5

  Yes

  No

  N/A

• Are flammables stored and labeled correctly? EC.02.02.01 EP 5 and 12

  Yes

  No

  N/A

• There are no items stored on top or in front of a flammable storage cabinet? EC.02.02.01. EP 5

  Yes

  No

  N/A

• Are no more than 10 gallons of flammable liquids stored outside a flammable cabinet? NFPA 101 Chapter 19.3.2; EC.02.02.01 EP 5

  Yes

  No

  N/A

• Does the unit have emergency procedures for handling hazardous spills or exposures? 29 CFR 1910.106(e)(9)(i); EC.02.02.01 EP 3

  Yes

  No

  N/A

• If the staff familiar with the location of the eyewash station? EC.02.02.01 EP 3; ANSI Z358

  Yes

  No

  N/A

• Are eyewash stations activated weekly and emergency showers activated monthly? Is there documentation of the checks? EC.02.02.01 EP 3 ANSI Z358

  Yes

  No

  N/A

• Is the pathway to the eyewash station or shower unimpeded (10 seconds to reach)? EC.02.02.01 EP 3 ANSI Z358

  Yes

  No

  N/A

BSL-2 DA PAM 385-69

• Does the laboratory supervisor enforce institutional policies that control access to the laboratory?

  Yes

  No

  N/A

• Do personnel have access and screened for or enrolled in appropriate medical surveillance program?

  Yes

  No

  N/A

• Do personnel wash hands after working with potentially hazardous materials and before leaving the laboratory?

  Yes

  No

  N/A

• Is eating, drinking, smoking, handling contact lenses, applying cosmetics, and storing food for human consumption not allowed in laboratory areas?

  Yes

  No

  N/A

• Is mouth pipetting prohibited; mechanical pipetting devices used?

  Yes

  No

  N/A

• Are sharps such as needles, scalpels, pipettes, and broken glassware handled safely?

  Yes

  No

  N/A

• Are work surfaces decontaminated after any spill or splash of potentially hazardous material?

  Yes

  No

  N/A

• Are potentially infectious materials decontaminated before disposal?

  Yes

  No

  N/A

• Are biosafety symbols at the entrances of the laboratory with supervisor's name (or other responsible person), telephone number

  Yes

  No

  N/A

• Are personnel entering the laboratory advised of the potential hazards?

  Yes

  No

  N/A

• Is the laboratory-specific biosafety manual available and accessible?

  Yes

  No

  N/A

• Is potentially infectious materials placed in a durable, leak-proof, container during collection, handling, processing, storage, or transport within the facility?

  Yes

  No

  N/A

• Is laboratory equipment routinely decontaminated?

  Yes

  No

  N/A

• Is laboratory equipment decontaminated after spills, splashes, or other potential contamination? I

  Yes

  No

  N/A

• is laboratory equipment decontaminated before repairs, maintenance, or removal from the laboratory?

  Yes

  No

  N/A

• Is PPE removed before leaving non-laboratory areas?

  Yes

  No

  N/A

• Are the doors of the laboratory self-closing and have locks?

  Yes

  No

  N/A

• Does the laboratory have a sink for hand washing and located near the exit door?

  Yes

  No

  N/A

• Is the laboratory furniture capable of supporting anticipated loads and uses?

  Yes

  No

  N/A

• Are spaces around benches, cabinets, and equipment accessible for cleaning?

  Yes

  No

  N/A

• Are laboratory chairs covered with non-porous material and can be easily decontaminated?

  Yes

  No

  N/A

• Are vacuum lines protected with HEPA filters or their equivalent?

  Yes

  No

  N/A

Safety Program Assessment

• Is the ADSO/CDSO on appointment orders and has appropriate training? EC.01.01.01 EP 1

  Yes

  No

  N/A

• Does the unit have a statement of authority to intervene in any unsafe act that can cause serious injury or death?

  Yes

  No

  N/A

• Does the clinic/area have reporting procedures that involve property damage, occupational illnesses and injury to staff, patients, and visitors?

  Yes

  No

  N/A

• Does the clinic/area identify hazards? Does the clinic/area perform self-inspections at least monthly to identify and mitigate hazards? Dos the clinic/area have a risk assessment for all duties and have staff members review the risk assessments? EC.02.01.01 EP 1

  Yes

  No

  N/A

• Does the clinic/area have procedures for emergencies? Does staff know what to do for each type of emergency?

  Yes

  No

  N/A

• Can the staff describe their role in any actual or simulated disaster?

  Yes

  No

  N/A

• Are all employees part of a continuing training program?

  Yes

  No

  N/A

• Are safety/EOC policies and procedures up to date? EC.01.01.01 EP 3 & 6

  Yes

  No

  N/A

• Can personnel describe or demonstrate safety risks in the environment of care? EC.03.01.01 EP 2

  Yes

  No

  N/A

• Do all newcomers receive Environment of Care training and job specific standards before starting work

  Yes

  No

  N/A

• Can personnel describe or demonstrate actions to eliminate, minimize or report safety risks in the environment? EC.03.01.01 EP 2

  Yes

  No

  N/A

• Does the unit have annual evaluations of the EC Elements? EC.04.01.01 EP 15

  Yes

  No

  N/A

• Does the clinic have quarterly safety committee Dmeeting minutes on file; Accident tracking log and hazard tracking log up to date? EC.04.01.01 EP 1, 2 & 5

  Yes

  No

  N/A

• Does the unit have 5 years of the OSHA 300 logs? EC.04.01.01 EP 4

  Yes

  No

  N/A

• Do the sections have a DRAW, JSA or SOPs for procedures when there are no other instructions that identify hazards, hazard mitigation, and how to safely work? EC.02.01.01 EP 1

  Yes

  No

  N/A

Safety Board Requirements (paper or electronic)

• Is the unit's Strategic Safety Plan specific, measurable, attainable, realisitic, and timely?

  Yes

  No

  N/A

• is there reporting procedures for accidents and hazards posted?

  Yes

  No

  N/A

• Is a section's risk assessment posted for all employees to access? (Not more than 12 months old)?

  Yes

  No

  N/A

• Is the Federal Safety and Occupational Heatlh Poster signed and available?

  Yes

  No

  N/A

• Does the unit display the command safety policy letters?

  Yes

  No

  N/A