Building Condition

Arctic entry - appropriate design and maintained?

Sound construction, easily cleanable?

Exam rooms -Is there 80 square ft; treatment rooms 120 square ft?

ADA compliant?

Storage adequate and organized?

Boiler and electrical rooms not being used to store combustibles?

Exam room doors 3' clearance?

All doors function correctly?

Bathrooms enclosed and staff able to open?

Secure lock for outside doors? Allows egress or sign posted to "Keep unlocked during Normal Business Hours"?

Patient privacy maintained through doors, curtains or opaque windows?


Installed to UPC by competent personnel?

Handwashing sinks in exam rooms?

Convenient to toilet?

Boiler room enclosed by 1 hour fire resistant barrier or sprinklered?

Hot water does not exceed 110 degrees F?

Heating and Ventilation (mechanical)

Appliances installed to code by competent personnel?

Outside air used for combustion and ventilation?

Heating - 68 - 72 degrees F when occupied?

10 ACH in toilet and shower room and Janitor Closets?

Boilers thermostatically controlled?

Boilers not set over 180 degrees F?

Boiler pressure not lower than 10 psig or higher than 20 psig?

Portable space heaters not in evidence?

Fuel tanks and connections installed to code?

Fuel lines supported and protected?

Flexible connectors used on fuel lines between fuel tank and building?

SPCCP in place if fuel tank exceeds 660 gallons?

Chemical toilet or box - and - pail type toilet if no water under pressure?

Utility sink with anti-syphon device, if water pressure available?

Backflow preventer installed, if equipped?

Annual backflow preventer inspection completed?

Fuel gas piping installed and maintained to code, if applicable?

All fixtures clean and in good repair?


Wiring installed and maintained according to NEC?

Sufficient receptacles available?

Each exam and worktable served by at least one duplex receptacle?

GFCI installed within 6' of a water source?

Tamper resistant outlets in Child Occupied areas?

Electrical Panel schedule current and updated?

3' clearance in front of electrical panels?

Cords or plugins NOT frayed, damaged, or worn?

Extension cords are NOT being used as "permanent" wiring?

Extension cords are NOT plugged into a UPS?

Multi-plex outlets are NOT "daisy chained"?

Appliances are UL Listed or listed by another independent safety lab?


Minimum light levels for prep/exam/desks 100FC?

Janitor's Closets 50FC?

General area and Toilets 20FC?

External entrance lighting available and sufficient?

Emergency lighting available?

30 second monthly and 90 minute annual testing completed?

Fixtures without lens, are they shielded with a tube type shield?


Furniture and carpet allow for cleaning?

Satellite or Landline phone available for emergency communication?


Potable water provided - clinic connected to community supply - if available?

Water source tested according to Alaska Department of Environmental Conservation (ADEC) standards?

Drinking fountains or single service cups available?

Hauled water delivered in approved containers and maintains sufficient residual chlorine?

Water storage containers appropriate and sanitized daily?

Non-tested water, if used, receives appropriate treatment?

Any emergency water receives disinfection provided by chlorination or boiling?

Sewage Disposal

Liquid waste systems operate as designed and dispose of waste in accordance with State of Alaska regulations?

Clinic connected to community sewer system if available?

Septic tanks, if used, appropriately placed, identified, and functioning correctly?

Sludge or "honey bucket" waste disposed of in permitted sites?

"Honey Buckets" emptied on a daily basis?

Refuse Sanitation

Solid waste appropriately disposed to limit injuries and spread of infection?

Solid waste containers not to exceed 32 gallons?

Exterior containers have lids to prevent spillage from wind and animals?

Regulated Medical Waste

Policy available on definition and procedures for handling?

Staff has been trained on "Red Bag" material?

Material in "Red Bag" containers is appropriate?


Needles are the automatic retractable type?

Containers of an approve design?

Containers are not more than 75% full?

Waste Collection Frequency

Waste collected on a daily basis?

Collection and storage des not create a health hazard or pollute water run-off?

Infection Control

Hand washing means provided and used for hand antisepsis; alcohol-based agent or antimicrobial soap?

ABHR available and accessible?

Clinics with running water, hand washing sinks available with soap, warm water, and paper towels located in toilet and exam rooms?

Clinics with no running water have appropriate containers with spigots in toilet and exam rooms?

Disinfection and Sterilization - Medical Equipment

Staff is appropriately trained?

Staff wears appropriate PPE during the process?

Process flows from "dirty" to "clean"?

Level of disinfection/sterilization based on use of equipment?

Chemical, mechanical, and or biological monitoring conducted?

Disinfected/sterilized packages rotated, intact, and not stored on the floor or under a sink?

A Recall Policy developed and "in force" for all disinfected/sterilized items?

Disinfection and Sterilization - General

All Surfaces disinfected with approved NSHC disinfection agents?

Any and all toys within the clinic are washed and disinfected when visibly contaminated and after each use?

Blood Borne Pathogens (BBP) spills are disinfected with approved NSHC disinfectant agents.

Proper Personal Protective Equipment (PPE) is worn when cleaning and BBP spills?

A written BBP Plan is in place and enforced?

Provisions of the Needle Stick Safety and Prevention Act are included?

Any broken contaminated glassware collected with a broom and dustpan and the area disinfected with appropriate agents?


Staff have been trained on proper cleaning procedures?

Clinic cleaned according to posted schedule or on a daily basis?

Cleaning supplies kept locked within the Janitor's Closet?

Occupational Health and Safety

Drugs and NARCS stored in a locked room and/or PickPoint unit?

Outdated or expired medication removed from patient medication storage area and properly disposed of or shipped back to the Pharmacy for disposal?

Lab specimens and other contaminants are separated from prescription medications?

Any toxic or hazardous materials stored separately from any food or medicines?

Incompatible chemicals separated from one another?

Poison Control phone number is posted within the clinic?

Refrigerator/freezer temperatures are being recorded and monitored either manually or remotely?

Fire Safety

Smoke detectors are online and operational?

Sleeping quarters have an operational smoke detector?

Fire extinguishers appropriately placed, readily visible, and not blocked?

Monthly and Annual testing has been completed according to National Fire Protection Association (NFPA) Standards?

Staff has received annual training on fire extinguisher use and documented?

Clinic has conducted annual fire drill and documented the event?

Exit signs placed appropriately?

Monthly 30 second testing and annual 90 minute testing completed according to NFPA Standards?

Boiler rooms enclosed by 1 hour barrier?

Pressure relief valves in place and "blow off" line situated to blow away from people?

Smoking is not done in clinic and is prohibited?

Hazardous Communication Program (HAZCOM)

Written HAZCOM Program implemented?

Do staff know where Safety Data Sheet (SDS) book is located?

SDS available in hardcopy and/or electronic format?

Departmental HAZCOM completed?

SDS book index current?

(Have staff search for SDS for 1 item within clinic) - SDS' current?

Hazardous Materials

Has an Asbestos Survey been conducted by a certified surveyor?

Was the building constructed after to 1980?

There is NO Thermal System Insulation(TSI), sprayed on/troweled, asphalt or sheet vinyl flooring in evidence?


Has a Lead Survey been conducted by a certified surveyor?

Was the building constructed after 1978?

Tuberculosis Precautions

Procedures available describing actions to take in the event of suspected TB?

Procedures in place to protect employees from exposure to TB?

Compressed Gases

Large cylinders have a valve cap screwed tightly to the cylinder when not in use?

Cylinders secured in a stand, cart, or attached to immovable object?

Oxygen supply equipment kept free of petroleum products?

Cylinders tagged with correct status - New, In Use, Empty?

Cylinders retested and stamped every 5 years for steel type and 10 years for aluminum?

Cylinders have oxygen manufacturer's label on them?

There is NOT more than 12 oxygen cylinders in the clinic?

If NO, how many?

Injury Control

Extension cords not attached to hot or heavy use devices?

There are NO poisonous or harmful plants?

Window shades with cords/strings NO longer than 6'?

There are NO sharp points or corners on any furniture?

Are all exits kept free and clear of debris, snow and ice, combustibles, and other hazards?

Are hand rails and ant-slip surfaces utilized on steps and ramps?

Joint Commission

Medical Records are kept confidential?

Hazard Surveillance Surveys conducted on a bi-annual basis?

Have all staff completed the Annual Safety Fair with a passing score?

Staff utilize there NSHC ID according to policy?

Copies of shipping manifests are kept for bio-hazardous and hazardous waste shipments?

Staff has been trained in IATA?

Annual Emergency Preparedness drills conducted according to standards?

Annual fire drill has been conducted and documented according to NFPA standards?

Fire suppression system (if equipped) has been tested by a licensed professional on an annual basis?

Fire alarm system (if equipped) has been tested by a licensed professional on an annual basis?

Medical equipment is on a preventive maintenance schedule?

Equipment has a current inspection tag?

Staff can show when the equipment has last been tested?


Is there a room set aside for traveling staff to stay in within the clinic?

Single station smoke detectors have been placed in each sleeping room?

Smoke detectors are functional?

Back up batteries have been replaced within the last year?

Is there a secondary means of egress per code?



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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.