SampleInspection Checklist

Dept/AreaInspected:Date:Inspectedby:

FloorsWalkways / Y/N / ActionRequired / Responsibilityof / DueDate
Aredoorwaysclearofmaterialsorequipment?
Arecarpetsortilesingoodcondition,freeof
looseorliftingcarpetingortile?
Ifsuppliesormaterialsstoredonthefloor-are
theyawayfromdoors/aisles?
Areheavyitemssuchaspaperproducts
certainequipmentstoredaboveshoulderlevel?
Areequipmentpaperproductsstoredontop
ofcupboards?
Aresuppliesmaterialsstoredproperly?
Doesyourstoragelayoutminimizelifting problems?
Aretrolleysordolliesavailableforheavyitems?
Arefloors aroundshelvesclearofrubbish?
Areracksshelvesingoodcondition?
Areshelvessufficient forweightused?
Isthere safeaccessforworkersvisitors?
Areemergencyexitsclear ofmaterials
equipment?
Areemergencyexitsignsworking?
Areemergencylighting unitsprovided?
Areallemergencylightsworking?
Areemergencyexitlightsproperlylocated?
Areemergencyexitfloorplansposted?

SampleInspection Checklist (continued)

Emergency Response / Y/N / ActionRequired / Responsibilityof / DueDate
Areemergencyresponseproceduresforfireotherhazards,likeviolence,clearlyunderstoodexercised/drilledregularly?
Areassignedfirstrespondersproperlytrained?
Aretheresufficientnumbersoffireextinguishers
aretheyclearlymarked?
Arefireextinguishersproperlyinstalledonwalls?
Havefireextinguishersbeeninspectedwithin the lastyear?
Areallworkerstrainedinfireprevention?
Areflammableliquidsproperlystored?
Willspaceheatersturnoffautomaticallywhen tippedover?
Areemergencyphonenumbersclosetophones?
Aresmoke,fire,burglar/panic alarmsinplace
aretheytestedregularly?
Emergency Response / Y/N / ActionRequired / Responsibility of / DueDate
Isthefirstaidkitaccessibleclearlylabeled?
Isthefirstaidkitadequatecomplete?
Isthefirstaidkitcleandry?
Areemergencynumbersdisplayed?
Areaccidentreportformsreadilyavailable?
Emergency Preparedness / Y/N / ActionRequired / Responsibility of / DueDate
IsaGeneralEmergency Preparednessplan
posted,doesitaddress:
ƒFlooding
ƒLandslide
ƒEarthquake
ƒSevereWeatherpolicies(e.g.winter driving)
xTerrorism ConsequencePreparedness
WorkerKnowledge Questions / Y/N / ActionRequired / Responsibilityof / DueDate
Doworkersknowwheretogowhotocall
forfirstaidassistance?
DoworkersknowwheretofindMSDS’sfor
chemicalproducts?
Doworkersknowwheretofindpersonal
protectiveequipment (PPE)?
Doworkersknowhowtousepersonal
protectiveequipment (PPE)?
Areworkerswearingappropriateclothing?
Areworkerswearingappropriatefootwear?
Areworkerstrainedintheuseoftheavailable
equipment?
Areworkerstrainedinsafeworkprocedures?
Dotheyfollow designatedprocedures?
Dotheyusethecorrecttechnique?
Dotheyknowhowtoreportunsafeconditions?
Dotheyknowhowtoreportaninjury?
Dotheyknowtowhomtoreportaninjury?
AretheyawareoftheMSIPProgram?
WorkerKnowledge Questions / Y/N / ActionRequired / Responsibilityof / DueDate
Isthegeneralcondition ofthefacilityequipmentingoodrepair,clean,unclutteredappropriateforintended use?
Doeslayoutofthefacilitythepositioningof equipment enhanceasafeworkflow?
Aresafetyconsiderationsextendedto employment-relateduseofpersonalvehicles
offsitework?
Werestaff,supervisorsmanagementsafety awareattentivetotheinspectionteam?
ParkingLot / Y/N / ActionRequired / Responsibility of / DueDate
Areparkingspotswalkwaysappropriatelylit?
Areparkingspotssafe(namesofindividuals shouldnotbeonparkingspots)?
Areworkersencouragedtouseabuddy or escort?
Isaspeedlimitpostedinparkinglot?
Furniture / Y/N / ActionRequired / Responsibilityof / DueDate
Isthefurniture clean?
Ingoodworkingorder?
Arechairsingoodcondition?
Arechairsproperlyadjustedadjustable?
Dochairsprovide adequatebacksupport?
SharpsDisposal / Y/N / ActionRequired / Responsibility of / DueDate
Areseparatecontainersavailable?
Aretheyclearlyidentified?
Aretheyaccessible?
HazardousMaterials / Y/N / ActionRequired / Responsibility of / DueDate
AreMSDSsprovidedforallhazardous
materials?
Arecontainersclearlymarked?
Arehazardousmaterialsproperlystored?
Arehazardousmaterialsdisposedofproperly?
WHMIS / Y/N / ActionRequired / Responsibility of / DueDate
Allcontrolledproductslabeled?
AreMSDSbindersaccessible?
AreMSDSsuptodate(lessthan3years)?
Isstaffawareoflocation ofMSDSbinder?
IsstafffamiliarwiththeWHMISprogram?
HavestaffhavereceivedWHMIStraining?
Emergency Eyewash/Showers / Y/N / ActionRequired / Responsibilityof / DueDate
Iseyewashsolutionavailable?
Areappropriatewashingproceduresavailable?
Isstaffusingappropriatewashingprocedures?
Beds/Stretchers / Y/N / ActionRequired / Responsibility of / DueDate
Heightadjustable?
Brakesinplace?
Brakesingoodworkingorder?
Siderailsinplace?
Siderailsingoodworkingorder?
Wheelsingoodworkingorder?
Isstaffawareoflocation?
Wheelchairs/Commodes / Y/N / ActionRequired / Responsibility of / DueDate
Appropriate chairsavailable?
Appropriatechairsaccessible?
Brakesingoodworkingorder?
Removablearmrests?
Removablefootrests?
Wheelsingoodworkingorder?
Otherfeaturesingoodworkingorder?
Isstaffawareoflocation?
Tubs / Y/N / ActionRequired / Responsibility of / DueDate
Isappropriatetubavailable?
Aretubseasilyaccessible?
Isheightadjustable?
Isthetubequippedwithapatientlift?
Isitingoodworkingorder?

SampleInspection Checklist (continued)

Mechanical Lifts / Y/N / ActionRequired / Responsibility of / DueDate
Areappropriateliftsavailable?
Areappropriateliftsaccessible?
Aretheyingoodworkingorder?
Arebrakesinplace?
Arebrakesingoodworkingorder?
Areappropriateaccessoriesavailable?
Areappropriateaccessoriesaccessible?
Isstafftrainedintheuse?
Isstaffawareoflocation?
MechanicalTransferAids / Y/N / ActionRequired / Responsibilityof / DueDate
Areappropriatetransferaidsavailable?
Areappropriatetransferaidsaccessible?
Aretheyingoodworkingorder?
Arebrakesinplace?
Arebrakesingoodworkingorder?
Areappropriateaccessoriesaccessible?
Isstafftrainedintheuse?
Isstaffawareoflocation?
Trolleys/Carts / Y/N / ActionRequired / Responsibility of / DueDate
Areappropriatetrolleys/cartsavailable?
Areappropriatetrolleys/cartsaccessible?
Heightadjustable?
Arebrakesinplace?
Arebrakesingoodworkingorder?
Isstaffawareoflocation?

SampleInspection Checklist:X-rayTechnologist

Dept/AreaInspected:Date:Inspectedby:

Technologists / Y/N / ActionRequired / Responsibilityof / DueDate
Arethetechnologistswearingtheappropriate personalprotectiveequipment(PPE-leadvests)?
Isthex-raymachineadjustable,toalloweasy accessforalltechnologist?
Doestechnologist usepropershoulderpostures whileworking?
Doesthetechnologist useproperback/trunk
postureswhileworking?
Isthepatientbedheightadjustable?
Lighting / Y/N / ActionRequired / Responsibility of / DueDate
Arelightinglevelsinwork areasadequate?
Arework areasfreeofglareorexcessivelighting contrast?
Istasklightingprovidedinareasoflowlightor highglare?
Arewindowscoveredwithblinds,drapesor
othermeansofcontrollinglight?
Doesemergencylighting work?
X-rayRoom / Y/N / ActionRequired / Responsibility of / DueDate
Istheroom properly sealedtoprotectx-rays
frompenetratingtheoutsideenvironment?
Aretherepropersignals(lights,signs)toindicate
whenthex-raymachineisbeingused?
Aretheindicatorlightsclearlyvisibleobvious?
Arenoiselevelscontrolled?
Istheworking areafreeofdebrisexcess
machinery?

SampleInspection Checklist:X-rayTechnologist(continued)

Electrical / Y/N / ActionRequired / Responsibilityof / DueDate
Areelectricalcordsingoodrepair?
Isthere clearaccesstoelectricalpanelsand switchgear?
Areelectricalcordssecured?
Areproperplugsused?
Areplugs,sockets,andswitches,ingood condition?
Aregroundfaultcircuitinterrupters available,if
required?
Areportablepower toolsingoodcondition?
Environment
Istheairqualitygood?
Areworkersprotectedfromcooldraftsor
excessiveheat?
Areworkersprotectedfromexcessiveirritating
noise?