Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

  • Restroom facilities clean and sanitary

  • Restroom facilities adequately stocked with the necessary supplies

  • Staff lounge and eating areas clean and sanitary

  • Drinking fountains clean and in good working order

  • Work areas free of rodents and insects

  • Ceiling fan blades safe and clean

  • Waste receptacles emptied regularly

  • Adequate type (tight-fitting covers where needed) and number of waste receptacles provided

  • Storage areas clean and clear of debris or clutter

  • Walls and woodwork clean

Signature

  • Any other comments?

  • When completed please provide signature here:

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