TJC - Tracer - Utilities

• Department
  Address

• Conducted on

  Date

• Prepared by:

• Location:
  Address

• Personnel

Utilities

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

  Yes

  No

  N/A

• Are electric panels properly secured or locked?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A