UHWI Public Health Inspection Form - duplicate

• Date of Inspection

  Date

• Name of Inspector

• Purpose of visit

  Routine

  Complaint

  Re-inspection

• Action

  Follow-up

  Nil

  Closure

• Ward/Dept/Unit

• 01 Absence of overcrowding

  Yes

  No

  N/A

• 02 Structural Integrity

  Good

  Fair

  Poor

  N/A

• 03 Condition of floors

  Good

  Fair

  Poor

  N/A

• 04 Condition of walls & windows

  Good

  Fair

  Poor

  N/A

• 05 Condition of ceilings

  Good

  Fair

  Poor

  N/A

• 06 Lighting adequacy

  Good

  Fair

  Poor

  N/A

• 07 Ventilation adequacy

  Good

  Fair

  Poor

  N/A

• 08 Potability

  Safe

  At Risk

  N/A

• Chlorine residual reading

• Chlorine residual reading

• 09 Condition of plumbing system (taps, pipes etc.)

  Good

  Fair

  Poor

  N/A

• 10 Water adequacy/availability

  Good

  Fair

  Poor

  N/A

• 11 Condition of water closets

  Good

  Fair

  Poor

  N/A

• 12 Condition of sewer system

  Good

  Fair

  Poor

  N/A

• 13 Condition of handwashing stations

  Good

  Fair

  Poor

  N/A

• 14 Condition of shower areas

  Good

  Fair

  Poor

  N/A

• 15 Food storage areas

  Satisfactory

  Unsatisfactory

  N/A

• 16 Condition of utensils, equipment, structural facilities etc.

  Good

  Fair

  Poor

  N/A

• 17 Condition of dining areas

  Good

  Fair

  Poor

  N/A

• 18 Food handling practices

  Good

  Fair

  Poor

  N/A

• 19 Condition of cold storage units

  Good

  Fair

  Poor

  N/A

Temperature logs (Food storage)

Unit 1 (chiller) Unit 1 (freezer) Unit 2 (chiller) Unit 2 (freezer)

• 20 Condition of cold storage units for non-food items

  Good

  Fair

  Poor

  N/A

temperature logs (Non-food storage)

Unit 3 (chiller) Unit 3 (freezer) Unit 4 (chiller) Unit 4 (freezer)

• 21 Waste segregation measures appropriate

  Yes

  No

  N/A

• 22 Condition of waste bins

  Good

  Fair

  Poor

  N/A

• 23 Use & storage of sharps boxes

  Good

  Fair

  Poor

  N/A

• 24 Fire extinguisher storage and maintenance

  Safe

  At Risk

  N/A

• 25 Presence of trip/slip/fall hazards

  Safe

  At Risk

  N/A

• 26 Presence of obstructions (e.g in walkways etc.)

  Safe

  At Risk

  N/A

• 27 Presence of ergonomic hazards

  Safe

  At Risk

  N/A

• 28 Presence of chemical hazards

  Safe

  At Risk

  N/A

• 29 Presence of biological hazards

  Safe

  At Risk

  N/A

• 30 Condition of emergency exits

  Safe

  At Risk

  N/A

• 31 Infection control practices

  Excellent

  Good

  Needs improvement

  Poor

  N/A

• 32 Evidence of infestation

  Yes

  No

• Treatment/ baits set

  Yes

  No

  N/A

• 33 Condition of beds, machines, monitors etc

  Good

  Fair

  Poor

  N/A

• 34 Handwashing stations adequate (amount, functioning & equipped)

  Good

  Fair

  Poor

  N/A

• 35 Cleaning schedule present

  Yes

  No

  N/A

• 36 Housekeeping staff observed while working

  Yes

  No

• Cleaning chemicals mixed/prepared appropriately

  Yes

  No

  N/A

• Cleaning technique used appropriately based on the item being cleaned

  Yes

  No

  N/A

• Appropriate PPE worn, donned and doffed according to approved standards

  Yes

  No

  N/A

• Hand hygiene performed correctly

  Yes

  No

  N/A

• Important concerns

• Inspector's signature

  Sign