Momentum-cares | SAFETY SELF-INSPECTION FORM

Step 1 of 3

33%

Today's Date:(Required)

MM slash DD slash YYYY

Quarter:(Required)

Inspector:(Required)

First Last

Signature(Required)

Email:(Required)

Are you uploading ONLY proof of an inspection?

ENTERANCE AND EXIT

Note: All boxes not marked require a response and corrective action:

1. Outside Property is maintained w/ safety precautions:(Required)

a. There are no apparent building code violations

b. There are no blocked access ways (good lighting)

c. There is no broken glass, debris

d. There are no plumbing problems

e. Other:

Identify the next steps to be taken:(Required)

(If no response put N/A) 1a. Inspector will have maintenance remove the desk that broke when relocating furniture within 24 hours.

Describe Other:(Required)

2. Outside Cleanliness, Property:(Required)

a. Areas are cleaned and orderly

b. There are no obvious health hazards

c. Is the outside free from clutter, litter?

d. Is the garbage properly contained?

e. Other

Identify the next steps to be taken:(Required)

Describe Other:(Required)

3. Inside Property is maintained w/ safety precautions:(Required)

a. Medical Records are locked and securely stored

b. Confidential information is secured

c. Emergency – Disaster plans are in place

d. First Aid kit maintained

e. Paints/cleaning supplies are in a secured place

f. Smoke detectors/fire extinguishers operational and checks completed

g. Water temperature in range

h. No overloaded outlets

i. No broken glass

j. Office structure/furniture in good repair

k. Properly operating windows

l. Air filters changed monthly

m. Other

Identify the next steps to be taken:(Required)

Describe Other:(Required)

4. Inside Cleanliness, Property is:(Required)

a. Cleaned and orderly in all areas

b. No obvious health hazards

c. No full garbage bags

d. No offensive odors

e. No food particles on the floor/tables

f. No grease/grim evident

g. No obvious insect/rodent problems

h. No dirty/sticky floors

i. Other

Identify the next steps to be taken:(Required)

Describe Other:(Required)

5. Documentation:(Required)

a. Record of completion of fire drills

b. Record of tornado/severe weather drills maintained

c. Record of yearly fire and sanitation inspections

d. Other

Identify the next steps to be taken:(Required)

Describe Other:(Required)

6. Postings:(Required)

a. Facility Licenses

b. Notice of Privacy Practices

c. Equal Employment Opportunity Law

d. Department of Labor Law Notice to Employees

e. Sign In/Out, confidentiality logs maintained

f. Emergency Evacuation posted at exits

g. Other

Identify the next steps to be taken:(Required)

Describe Other:(Required)

Fire Inspection:(Required)

Date of Inspection:(Required)

Month

Day

Year

Upload a copy of inspection:

Max. file size: 512 MB.

First Aid Kit:(Required)

Date of Expiration:(Required)

Month

Day

Year

Photo of Kit Expiration Date:

Max. file size: 512 MB.

Number of Fire Extinguishers:(Required)

Are the fire extinguishers tagged and inspected:(Required)

Date of Inspected:(Required)

Month

Day

Year

Photo of each tagged extinguisher:

Max. file size: 512 MB.

SAFETY SELF-INSPECTION FORM

ENTERANCE AND EXIT

Become a client