IMPORTANT: Periodic inspection of your organization’s buildings and grounds can alert you and your maintenance staff to hazards which may cause damage and accidents to your buildings and those who use it. This form is provided for periodic self-inspection and is recommended for use on a quarterly basis to assist you in discovering hazards before an accident can occur. Correct all negative conditions immediately.
This self-inspection form does not intend to point out all hazards and exposures which may be found at your building. It is intended to be used as a guide to highlight major areas of exposure which are common to most public entity buildings. The use of this form does not warrant that all hazards will be found and corrected.
INSTRUCTIONS: Please check Yes, No or NA (not applicable) answers to all questions below. All “No” answers indicate an area of unsatisfactory conditions and comment regarding same should be made in the space provided on the back of this form. Use a separate sheet for each building.
NAME OF ORGANIZATION:___________________________________________________________________________
BUILDING LOCATION:________________________________________________________________________________________ (Street Number) (City)
___________________________________________________________________________________________________ (County) (State) (Zip Code)
NAME OF INSPECTOR: __________________________________ DATE OF INSPECTION_____________________
GROUNDS
- Are parking areas, walkways, stairs, driveways, etc. free from conditions that may cause slipping or falling?
- __________YES __________NO __________NA
- Is exterior lighting adequate in all areas?
- __________YES __________NO __________NA
- Are all exterior stairs provided with handrails which are in good condition?
- __________YES __________NO __________NA
- Are exterior fire escapes in good condition?
- __________YES __________NO __________NA
- Is exterior storage of trash and rubbish at least 25 feet away from the building?
- __________YES __________NO __________NA
INTERIOR DOORS AND STAIRWAYS
- Are all exit doors properly marked?
- __________YES __________NO __________NA
- Are all exit doors easily accessible?
- __________YES __________NO __________NA
- Do all exit doors open outward?
- __________YES __________NO __________NA
- Are all exit doors equipped with panic hardware?
- __________YES __________NO __________NA
- Are all doors easily opened and closed?
- __________YES __________NO __________NA
- Are all doorways and areas adjacent to them free of obstructions?
- __________YES __________NO __________NA
- Are full length, clear glass doors and windows properly identified?
- __________YES __________NO __________NA
- Do all interior stairs have anti-slip treads?
- __________YES __________NO __________NA
- Are stairway and exit doors kept closed at all times?
- __________YES __________NO __________NA
- Do all interior stairways have properly secured hand rails?
- __________YES __________NO __________NA
- Are interior stairways kept free of storage and obstructions?
- __________YES __________NO __________NA
- Are interior stairways properly lighted?
- __________YES __________NO __________NA
- Is the emergency lighting system tested on a monthly basis?
- __________YES __________NO __________NA
- Is the emergency power generator tested on a weekly basis?
- __________YES __________NO __________NA
HEATING AND AIR CONDITIONING EQUIPMENT
- Has heating equipment been thoroughly inspected by a qualified individual within the past year?
- __________YES __________NO __________NA
- Is heating equipment (including flues and pipes) properly insulated from combustible materials?
- __________YES __________NO __________NA
- Are heating and air conditioning equipment rooms free of storage?
- __________YES __________NO __________NA
- Are heating and air conditioning rooms restricted areas
- __________YES __________NO __________NA
- Is air conditioning equipment cleaned and serviced annually?
- __________YES __________NO __________NA
ELECTRICAL EQUIPMENT & CONTROL PANELS
- Has the electrical system been inspected within the past ten years by acertified electrician or electrical inspector?
- __________YES __________NO __________NA
- Are electrical panels kept closed?
- __________YES __________NO __________NA
- Are electrical panels kept clear of storage and obstructions?
- __________YES __________NO __________NA
- Is circuitry adequate to handle load demand (not requiring frequent fuse replacement or circuit breaker resetting)?
- __________YES __________NO __________NA
- Was electrical system installed by a competent electrician?
- __________YES __________NO __________NA
- Is electrical system regularly maintained by a competent electrician?
- __________YES __________NO __________NA
- Are all electrical appliances properly grounded and cleaned?
- __________YES __________NO __________NA
- Are electric motors adequately ventilated to prevent overheating and are they cleaned regularly?
- __________YES __________NO __________NA
- Are proper size electrical cords used and are they in good condition?
- __________YES __________NO __________NA
KITCHEN EQUIPMENT-COMMERCIAL TYPE _______NA – Section
- Is all commercial cooking equipment properly protected?
- __________YES __________NO __________NA
- Is hood and duct exhaust system installed properly?
- __________YES __________NO __________NA
- Are grease filters U.L. listed for grease extraction and installed properly?
- __________YES __________NO __________NA
- Are the hood and duct systems clean (at least on a semi-annual basis)?
- __________YES __________NO __________NA
- Are the kitchen appliances protected with an automatic fire extinguishing system?
- __________YES __________NO __________NA
- Is the fire extinguishing system serviced and inspected
- __________YES __________NO __________NA
HOUSEKEEPING
- Are storage and supply rooms kept clean and orderly?
- __________YES __________NO __________NA
- Are trash and rubbish stored in metal containers?
- __________YES __________NO __________NA
- Are all flammable items (paint, lacquer, paint thinner, etc.) kept in safety containers and stored in approved metal cabinets?
- __________YES __________NO __________NA
- Are compressed gas cylinders properly secured?
- __________YES __________NO __________NA
- Are only non-flammable cleaning agents used throughout the entire building?
- __________YES __________NO __________NA
- Is ready disposal of combustible wastes provided?
- __________YES __________NO __________NA
- Are areas used for public meetings or other functions always thoroughly checked before securing?
- __________YES __________NO __________NA
- Are rags, cloths, etc. used in cleaning stored in an approved, self- closing metal container?
- __________YES __________NO __________NA
ROOF
- Roof inspection completed within the past 6 months?
- __________YES __________NO __________NA
Date completed:____________________________________
FIRE EXTINGUISHERS
- Are all the fire extinguishers tagged, serviced and inspected annually?
- __________YES __________NO __________NA
- Are all fire extinguishers tagged with latest service record and inspection date?
- __________YES __________NO __________NA
- Are fire extinguishers located within 75 feet from any point on each floor?
- __________YES __________NO __________NA
- Are extinguishers properly protected from damage and freezing?
- __________YES __________NO __________NA
FIRE/SMOKE DETECTION ________NA – Section
- Is building protected with smoke/heat detection system?
- Is smoke/heat detection system tested and inspected on a quarterly basis?
AUTOMATIC SPRINKLERS _________NA – Section
- Is there a two inch drain test performed on the sprinkler system on a quarterly basis?
- __________YES __________NO __________NA
- Gauge Readings:_____________________City_____________________System (Air / Water)__________________
CLEAN AGENT EXTINGUISHING SYSTEMS ___________NA – Section
- Has the system been inspected by a qualified person in the past 12 months?
- Gauge Reading:_______________________________________
SCIENCE LABS _____________NA – Section
- Are emergency eye wash and showers inspected (annual??)
- __________YES __________NO __________NA
- Are safety rules posted?
- __________YES __________NO __________NA
- Are chemicals stored based on compatibility?
- __________YES __________NO __________NA
- Are gas shutoff valves operating properly?
- __________YES __________NO __________NA
POOLS __________NA – Section
- Is the chlorine/disinfectant storage adequate?
- __________YES __________NO __________NA
- Are safety rules posted?
- __________YES __________NO __________NA
- Are depth markers provided and visible?
- __________YES __________NO __________NA
BLEACHERS __________NA – Section
- Is perimeter fall protection provided?
- __________YES __________NO __________NA
- Are all edges (seats and stairs) are smooth?
- __________YES __________NO __________NA
- Are supports free from defects and damage?
- __________YES __________NO __________NA
INDUSTRIAL ARTS ___________NA – Section
- Dust collection systems are in proper working order?
- __________YES __________NO __________NA
- Area is free of dust accumulation?
- __________YES __________NO __________NA
- Is housekeeping good?
- __________YES __________NO __________NA
- Are flammable liquids properly stored?
- __________YES __________NO __________NA
- Are safety rules posted?
- __________YES __________NO __________NA
- Are machine guards in place?
- Are welding areas segregated from combustibles?
- __________YES __________NO __________NA
ART ROOMS ___________NA – Section
- Is adequate clearance provided for kilns?
- __________YES __________NO __________NA
- Is chemical storage adequate?
- __________YES __________NO __________NA
- Is housekeeping good?
- __________YES __________NO __________NA
AUDITORIUMS ___________NA – Section
- Are all exits identified by illuminated exit signs?
- __________YES __________NO __________NA
- Are emergency lighting units working?
- __________YES __________NO __________NA
- Is housekeeping good?
- __________YES __________NO __________NA
- Is all rigging handled by qualified individuals?
- __________YES __________NO __________NA
- Are all seats in good condition?
- __________YES __________NO __________NA
COMMENTS: (If an explanation is needed for the above questions, please comment below. If any “NO” block is checked, indicate action taken and date to be corrected.)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
ITEM:
ACTION TAKEN:
CORRECTION BY:
DATE CORRECTED: