Title Page

  • Conducted on

  • Unit Safety Champion

  • Performed By

  • Building

  • Department

Patient Management

  • Staff demonstrate safe patient re-positioning?

  • Staff demonstrate safe patient transfers?

  • Staff demonstrate safe patient transfer to a different level?

  • Staff have been trained on the use of patient lifting equipment?

  • Staff have access to re-positioning sheets and gait belts?


  • All lighting is functional?

  • Ceiling tiles are clean and intact?

  • No visible signs of plumbing leaks? No water found under the sinks, around toilets or around ice machines.

  • Flooring is free of trip hazards?

  • Wet floor signs are posted properly?

  • All doors open and close properly?

  • All appliances are in working order?

  • All food is covered, dated and labeled?


  • All staff have name badges visible above the waist?

  • Staff knows how to contact security?

  • Emergency contact numbers are present on all phones?

  • Security alarms are functioning properly? Including panic devices, HUGS alarms, door prop alarms.

  • Intercom system can be heard in all areas?

  • All locks are working properly?

  • Staff personal property securely locked away?<br>

  • Staff have access to parking lot escorts?

  • Security patrols units and parking lots on a regular basis?


  • All electrical cords are in good condition?

  • Extension cords are not used in place of permanently installed fixed wiring?

  • A lock-out/tag-out procedure is in place and staff is trained regarding these procedures?

  • Relocatable power taps are of the appropriate type?

Storage Areas

  • Aisles are clear and the floor is clean?

  • Shelves and racks are of adequate strength and are secured?

  • Heavy items stored on shelves between the knee and shoulder height?

  • No material over 30 lbs. stored at more than five feet above floor?

  • Sharp edges are identified and eliminated?

  • Bump hazards are eliminated?

  • Falling object hazards are eliminated?

  • Employee locker rooms are clear and free of hazards?


  • Exit routes are unobstructed?

  • Exits are clearly marked with illuminated signs?

  • Emergency lighting provided for all occupied areas and tested?

  • Emergency evacuation plans posted?

  • All doors in exit path are kept closed?

  • Lighting is adequate?<br>

  • Adequate number of exits are provided?

  • Exit doors are operable in the path of exit travel without the use of a key or any special knowledge?


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.