Audit

Key:
O-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. Enforce 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 Predparedness

Sharps/ Needle Exposure

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

TB Exposure

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Chemical Exposure

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Lasers in use

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Blood and Body Fluid Exposure

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

X-ray Exposure

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Falls

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Ergonomics

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Fire

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

ADA Violations

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Assault

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Theft

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Suicide

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

HIPPA

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media

Utilities

Score.
Probability. 1-10
Risk. 1-10
Preparedness. 1-10
Total

Add media
Comments
Select date
Add signature
Forwarding instructions
Send completed copy to Facility Engineering: Attention Safety
E-Mail completed report to: Michael.huff@stdavids.com
Keep a copy for your Department 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.