Sapling Grove Surgery Exit Lighting Inspection

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

#1 - Waiting Area

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#2 - Waiting Area

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#3 - Waiting Area

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#4 - Door to Waiting Area

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#5 - Pre Op

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#6 - Pre Op

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#7 - Main Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#8 - Main Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#9 - Main Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#10 - Stairs Door Main Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#11 - Suite Front Door

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#12 - Supply Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#13 - O.R. Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#14 - O.R. Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#15 - O.R. Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#16 - Back Door O.R.

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#1 - Main Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#2 - Waiting Area

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#3 - Pre Op

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#4 - Supply Hall

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

#5 - Electrical Room

• Pass / Fail

  Pass

  Fail

• Replace Date

  Date

• Time (in seconds)

• Corrective Action

• This signature certifies that I have reviewed and completed the inspection.

  Sign