• Organization

  • Building/Floor/Area

  • Unit

  • Manager

  • Unit Representative on tour

  • Vice President

  • Conducted on

  • Prepared by

  • Personnel on Tour


  • Has the last audit been reviewed?

  • Have all outstanding concerns been addressed?

  • Tap to enter information
  • Identify outstanding concerns.


  • 1) Hallways clear of clutter.

  • 2) Exit doors unobstructed.

  • 3) No propped doors.

  • 4) Storage (boxes etc.) and equipment are no less than 18" from the bottom of sprinkler head.

  • 5) Storage (boxes etc.) are 6" above floor.

  • 6) No cracked, stained, or missing ceiling tiles. Escutcheons properly installed for penetrations.

  • 7) No codes written on access control doors.

  • 8) All junction boxes/switch plates are covered.

  • 9) No damaged building materials (e.g. ceilings, caulking, corner casing, ceiling penetration, cove base, door, floor tile, wall board, wall penetrations)


  • 10) Staff can identify Emergency Response Resources.<br>Safety info on ID<br>TJUH Intranet<br>Emergency Response Card

  • 11) Staff are wearing ID cards.

  • 12) Employees know how to access SDSs, Chemical Inventory List available.

  • 13) Personal items kept secured in work areas. (Handbags, Wallets, etc)

  • 14) Employees know the process for reporting a security incident, chemical spill, Code Red.<br>Dial 811/77

  • 15) Staff knows who can shut off medical gases in an emergency.

  • 16) Staff demonstrates knowledge of Code D/Disaster response.

  • 17) Personal Protective Equipment (PPE) available and worn when necessary.


  • 18) Electrical closet/panels, mechanical closets, housekeeping closets are locked.

  • 19) Fire extinguishers are clearly marked (signage).

  • 20) Fire extinguishers unobstructed.

  • 21) Fire extinguisher tag shows monthly inspection (format mm/dd/yr) & current annual tag

  • 22) Exit signs are sufficient, illuminated, clearly and correctly marked.

  • 23) Pull stations unobstructed (3' clear) and intact.

  • 24) Smoke/Fire Doors close freely. (Positive latch)

  • 25) No smoking policy enforced (no visible signs of non-compliance).

  • 26) Fire Tower Exits unlocked from floor (unless approved variance - special conditions).

  • 27) Proper stair identification signage at landings.

  • 28) Fire evacuation diagram signage posted at elevator call stations/landings.

  • 29) Medical gas shut-off valves are unobstructed and labeled to indicate the area served.

  • 30) Access control devices (card readers, combination locks) are in use and working properly.

  • 31) Area is adequately lighted.

  • 32) Sprinkler heads are free of foreign materials.

  • 33) No unauthorized appliances (e.g. fans, space heaters, toasters).

  • 34) Extension cords are not substituted for permanent wiring. (only approved surge power strips)

  • 35) Entrances to areas storing hazardous chemicals are labeled properly. (NFPA Diamond)

  • 36) Chemicals stored properly.

  • 37) Gas cylinders properly secured. <br>Gas storage area has a labeled door stating "Caution oxidizing gases stored within. No smoking"


  • 38) Are the major monitoring areas of equipment?

  • 38A -clean and free from damage.

  • 38B -equipment is free of frayed wires and/or faulty plugs.

  • 38C -carts are clean and free of rust

  • 39) Users of equipment is surveyed for recurring problems.

  • 40) Rechargeable equipment is plugged into a receptacle

  • 41) Equipment is being routinely inspected as indicated by the Equipment management Plan.


  • 42) Alcohol based hand washing solution readily available (staff handwashing).

  • 43) Clean linen cart covered, no items stored on top.

  • 44) No food or drink in clinical work area.

  • 45) Refrigerator log completed and up to date.

  • 46) Clean and soiled linen are separated and never stored together.

  • 47) Standards of cleanliness are maintained throughout.

  • 48) HVAC vents free of dust.

  • 49) Required eye-wash station(s) installed and operational per ANSI Z358.1 standards.

  • 50) Ice machines clean. no scale or growth on dispensing chutes and tubes.


  • Is there any additional findings?

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  • Additionally findings 1:

  • Is there any additional findings?

  • Tap to enter information
  • Additionally findings 2:

  • Is there any additional findings?

  • Tap to enter information
  • Additionally findings 3:


  • Department/Unit Representative

  • EOC Staff member leading tour

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.