Title Page

  • Site conducted

  • Site conducted

  • Conducted on

  • Prepared by

  • Location


  • Door is closed and locked if appropriate

  • Area is clean

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • Adequate separation of clean and soiled

  • No supplies stored on the floor

  • Bottom shelf barriers are in place and are 6 inches from the floor

  • Items stored are 18 inches from the ceiling

  • Equipment stored is clean

  • No expired supplies

  • Sinks are clean and in good condition

  • Nothing inappropriate is stored under the sinks

  • Additional findings

Meeting Rooms and Staff Lounges

  • Furniture is clean and in good condition

  • Area is clean and items are appropriately stored

  • No patient care items

  • Additional findings

Equipment and Non-Critical Items

  • Computer equipment is clean, in good condition, and with no tape

  • Equipment is clean

  • Additional findings

Waste Management

  • Biohazard bags are used appropriately

  • Waste containers are clean, operational, in good condition, and not overfilled

  • Waste containers are covered and labeled as required

  • Red bag is available in regulated medical waste container

  • Items in regulated medical waste containers are appropriate

  • Sharps container is available, secured appropriately, and not overfilled

  • Additional findings

Hand Hygiene

  • Hand hygiene is performed when appropriate (if observed)

  • Appropriate glove use (if observed)

  • Sinks are available, clean, and in good condition

  • Soap is available and not expired

  • Paper towels are available

  • Alcohol-based hand rub is available and not expired

  • Additional findings

General Environment

  • Floors are clean and in good condition

  • Walls are clean and in good condition

  • Ceiling is clean and in good condition

  • Air vents are clean and in good condition

  • Light fixtures are clean and in good condition

  • High-level dusting is performed

  • Area is free of roaches, flies, mice, and other vermin

  • Additional findings


  • Signage is laminated and not taped

  • Food and beverages are only in designated areas

  • No inappropriate items on windowsills

  • Cleaning supplies are not stored with patient care items

  • No outside shipping/corrugated cardboard boxes

  • No items/surfaces that cannot be cleaned in patient care areas

  • Additional findings


  • Food is covered and labeled per policy

  • No expired food or beverage items

  • Food is stored at appropriate temperatures (41°F and below for cold food storage; 0°F and below for frozen food storage; 140°F and above for hot food storage)

  • Cleaning items are not stored with food or beverages

  • Staff food/beverages and belongings are appropriately stored and labeled

  • Staff hair is secured

  • Additional findings

EVS and Agiliti

  • Equipment is clean or has been recently changed out

  • No buildup of waste

  • Additional findings


  • There is separation of clean and soiled linen

  • Clean linen is stored in required area, on shelves, or on covered carts

  • Clean linen is properly covered or sealed to prevent contamination during transport

  • Linen hampers and carts are clean and in good condition

  • Linen carts have solid surface on the bottom shelf

  • Laundry chutes are maintained

  • Additional findings


  • No application of cosmetics in the laboratory work area (if observed)

  • Staff hair is secured

  • Eyewash stations are checked weekly and documented on the tag

  • Additional findings


  • No outdated/expired medications

  • Open vials are dated and timed as per policy

  • Medications are disposed of properly

  • Medications are stored appropriately

  • Additional findings

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.