Resource:Self-Inspection Form for Building & Grounds

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 emergency service organization 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

  1.  Are parking areas, walkways, stairs, driveways, etc. free from conditions that may cause slipping or falling?
    • __________YES          __________NO          __________NA
  2.  Is exterior lighting adequate in all areas?
    • __________YES          __________NO          __________NA
  3. Are all exterior stairs provided with handrails which are in good condition?
    • __________YES          __________NO          __________NA
  4. Are exterior fire escapes in good condition?
    • __________YES          __________NO          __________NA
  5. Is exterior storage of trash and rubbish at least 25 feet away from the building?
    • __________YES          __________NO          __________NA

INTERIOR DOORS AND STAIRWAYS

  1. Are all exit doors properly marked?
    • __________YES          __________NO          __________NA
  2. Are all exit doors easily accessible?
    • __________YES          __________NO          __________NA
  3. Do all exit doors open outward?
    • __________YES          __________NO          __________NA
  4. Are all exit doors equipped with panic hardware?
    • __________YES          __________NO          __________NA
  5. Are all doors easily opened and closed?
    • __________YES          __________NO          __________NA
  6. Are all doorways and areas adjacent to them free of obstructions?
    • __________YES          __________NO          __________NA
  7. Are full length, clear glass doors and windows properly identified?
    • __________YES          __________NO          __________NA
  8. Do all interior stairs have anti-slip treads?
    • __________YES          __________NO          __________NA
  9. Are stairway and exit doors kept closed at all times?
    • __________YES          __________NO          __________NA
  10. Do all interior stairways have properly secured hand rails?
    • __________YES          __________NO          __________NA
  11. Are interior stairways kept free of storage and obstructions?
    • __________YES          __________NO          __________NA
  12. Are interior stairways properly lighted?
    • __________YES          __________NO          __________NA
  13. Is the emergency lighting system tested on a monthly basis?
    • __________YES          __________NO          __________NA
  14. Is the emergency power generator tested on a weekly basis?
    • __________YES          __________NO          __________NA

HEATING AND AIR CONDITIONING EQUIPMENT

  1. Has heating equipment been thoroughly inspected by a qualified individual within the past year?
    • __________YES          __________NO          __________NA
  2. Is heating equipment (including flues and pipes) properly insulated from combustible materials?
    • __________YES          __________NO          __________NA
  3. Are heating and air conditioning equipment rooms free of storage?
    • __________YES          __________NO          __________NA
  4. Are heating and air conditioning rooms restricted areas
    • __________YES          __________NO          __________NA
  5. Is air conditioning equipment cleaned and serviced annually?
    • __________YES          __________NO          __________NA

ELECTRICAL EQUIPMENT & CONTROL PANELS

  1. Has the electrical system been inspected within the past ten years by acertified electrician or electrical inspector?
    • __________YES          __________NO          __________NA
  2. Are electrical panels kept closed?
    • __________YES          __________NO          __________NA
  3. Are electrical panels kept clear of storage and obstructions?
    • __________YES          __________NO          __________NA
  4. Is circuitry adequate to handle load demand (not requiring frequent fuse replacement or circuit breaker resetting)?
    • __________YES          __________NO          __________NA
  5. Was electrical system installed by a competent electrician?
    • __________YES          __________NO          __________NA
  6. Is electrical system regularly maintained by a competent electrician?
    • __________YES          __________NO          __________NA
  7. Are all electrical appliances properly grounded and cleaned?
    • __________YES          __________NO          __________NA
  8. Are electric motors adequately ventilated to prevent overheating and are they cleaned regularly?
    • __________YES          __________NO          __________NA
  9. Are proper size electrical cords used and are they in good condition?
    • __________YES          __________NO          __________NA

KITCHEN EQUIPMENT-COMMERCIAL TYPE          _______NA – Section

  1. Is all commercial cooking equipment properly protected?
    • __________YES          __________NO          __________NA
  2. Is hood and duct exhaust system installed properly?
    • __________YES          __________NO          __________NA
  3. Are grease filters U.L. listed for grease extraction and installed properly?
    • __________YES          __________NO          __________NA
  4. Are the hood and duct systems clean (at least on a semi-annual basis)?
    • __________YES          __________NO          __________NA
  5. Are the kitchen appliances protected with an automatic fire extinguishing system?
    • __________YES          __________NO          __________NA
  6. Is the fire extinguishing system serviced and inspected 
    • __________YES          __________NO          __________NA

HOUSEKEEPING

  1. Are storage and supply rooms kept clean and orderly?
    • __________YES          __________NO          __________NA
  2. Are trash and rubbish stored in metal containers?
    • __________YES          __________NO          __________NA
  3. Are all flammable items (paint, lacquer, paint thinner, etc.) kept  in safety containers and stored in approved metal cabinets?
    • __________YES          __________NO          __________NA
  4. Are compressed gas cylinders properly secured?
    • __________YES          __________NO          __________NA
  5. Are only non-flammable cleaning agents used throughout the entire building?
    • __________YES          __________NO          __________NA
  6. Is ready disposal of combustible wastes provided?
    • __________YES          __________NO          __________NA
  7. Are areas used for public meetings or other functions always thoroughly checked before securing?
    • __________YES          __________NO          __________NA
  8. Are rags, cloths, etc. used in cleaning stored in an approved, self- closing metal container?
    • __________YES          __________NO          __________NA

 ROOF

  1. Roof inspection completed within the past 6 months?
    • __________YES          __________NO          __________NA

Date completed:____________________________________                                                      

FIRE EXTINGUISHERS

  1.  Are all the fire extinguishers tagged, serviced and inspected annually?
    • __________YES          __________NO          __________NA
  2. Are all fire extinguishers tagged with latest service record and inspection date?
    • __________YES          __________NO          __________NA
  3. Are fire extinguishers located within 75 feet from any point on each floor?
    • __________YES          __________NO          __________NA
  4. Are extinguishers properly protected from damage and freezing?
    • __________YES          __________NO          __________NA

FIRE/SMOKE DETECTION             ________NA – Section

  1. Is building protected with smoke/heat detection system?
  2. Is smoke/heat detection system tested and inspected on a quarterly basis?

AUTOMATIC SPRINKLERS            _________NA – Section

  1. Is there a two inch drain test performed on the sprinkler system on a quarterly basis?
    • __________YES          __________NO          __________NA
  2. Gauge Readings:_____________________City_____________________System (Air / Water)__________________

CLEAN AGENT EXTINGUISHING SYSTEMS        ___________NA – Section

  1. Has the system been inspected by a qualified person in the past 12 months?
  2. Gauge Reading:_______________________________________                     

SCIENCE LABS                  _____________NA – Section

  1. Are emergency eye wash and showers inspected (annual??)
    • __________YES          __________NO          __________NA
  2. Are safety rules posted?
    • __________YES          __________NO          __________NA
  3. Are chemicals stored based on compatibility?
    • __________YES          __________NO          __________NA
  4. Are gas shutoff valves operating properly?
    • __________YES          __________NO          __________NA

POOLS             __________NA – Section

  1. Is the chlorine/disinfectant storage adequate?
    • __________YES          __________NO          __________NA
  2. Are safety rules posted?
    • __________YES          __________NO          __________NA
  3. Are depth markers provided and visible?
    • __________YES          __________NO          __________NA

BLEACHERS      __________NA – Section

  1. Is perimeter fall protection provided?
    • __________YES          __________NO          __________NA
  2. Are all edges (seats and stairs) are smooth?
    • __________YES          __________NO          __________NA
  3. Are supports free from defects and damage?     
    • __________YES          __________NO          __________NA

INDUSTRIAL ARTS         ___________NA – Section

  1. Dust collection systems are in proper working order?
    • __________YES          __________NO          __________NA
  2. Area is free of dust accumulation?
    • __________YES          __________NO          __________NA
  3. Is housekeeping good?
    • __________YES          __________NO          __________NA
  4. Are flammable liquids properly stored?
    • __________YES          __________NO          __________NA
  5. Are safety rules posted?
    • __________YES          __________NO          __________NA
  6. Are machine guards in place?
    •  
  7. Are welding areas segregated from combustibles?
    • __________YES          __________NO          __________NA

ART ROOMS           ___________NA – Section

  1. Is adequate clearance provided for kilns?
    • __________YES          __________NO          __________NA
  2. Is chemical storage adequate?
    • __________YES          __________NO          __________NA
  3. Is housekeeping good?
    • __________YES          __________NO          __________NA

AUDITORIUMS           ___________NA – Section

  1. Are all exits identified by illuminated exit signs?
    • __________YES          __________NO          __________NA
  2. Are emergency lighting units working?
    • __________YES          __________NO          __________NA
  3. Is housekeeping good?
    • __________YES          __________NO          __________NA
  4. Is all rigging handled by qualified individuals?
    • __________YES          __________NO          __________NA
  5. 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.)

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ITEM:

ACTION TAKEN:

CORRECTION BY:

DATE CORRECTED: