Title Page

  • Department
  • Conducted on

  • Prepared by:

  • Location:
  • Personnel


  • Are items stored at least 36" from electrical panels?

  • Are electric panels properly secured or locked?

  • Are electric panel switch labels accurate and are all spares in the off position?

  • Are all mechanical and electrical rooms clean and have no storage? Indicate which rooms are not clean in the notes section.

  • Are medical gas zone shut-off valves accessible and unobstructed?

  • Are medical gas zone shut-off valves properly labeled for area served?

  • Do clean utility, sterile storage, medication rooms, and other clean/sterile areas have positive air pressure to the corridor/adjacent areas?

  • Do soiled utility, trash, hazardous waste, and other dirty rooms have negative air pressure to the corridor/adjacent areas?

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