• Location
  • Prepared by

  • Conducted on

  • Other personnel attending the inspection


  • Proper signs posted and clearly identified "REFUGE STATION"?

  • Is access clearly illuminated?

Fire Extinguishers

  • Are fire extinguishers available and accessible?

  • Do the fire extinguishers have their monthly compliance stamp?


  • Is approach to Refuge Station free of garbage and debris?

  • Is the air lock clean and orderly at the time of inspection?

Safety Equipment

  • General condition of the stretcher and accessories

  • Is the first aid kit sealed?

  • Is adequate door sealant available? (Required only in C9290 refuge)

  • Independent air supply (oxygen generator)

  • Emergency water and food supply

  • Temperature control equipment

  • Is the gas testing equipment functioning correctly?


  • Are sign off sheets in case of emergency available

  • Is the telephone working?

  • Is the radio working?

  • Is the PED working?

  • Is the Code of Conduct for Persons Occupying the Refuge Station posted inside?

  • Is there an up to date copy of the Mine Ventilation Plan and escape routes posted?

General comments

  • Enter comments here

  • Add signature

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.