Cath Lab Site Assessment

Cath Lab Site Assessment
Please complete this form to provide a comprehensive assessment of the catheterization laboratory site, including facility, equipment, staffing, and safety protocols.
Facility Name
Facility Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person Name
First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Assessment Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Equipment Inventory & Status
Rows Available Functional Needs Maintenance
Angiography System 1 2 3
Patient Monitoring System 4 5 6
Defibrillator 7 8 9
Contrast Injector 10 11 12
Lead Aprons 13 14 15
Radiation Shields 16 17 18
Staffing Compliance
Rows Present Certified Not Present
Interventional Cardiologist 19 20 21
Cath Lab Nurse 22 23 24
Radiology Technician 25 26 27
Anesthesiologist 28 29 30
Safety and Emergency Protocols
Other
Infection Control Measures
Other
Facility Maintenance Status
Overall Site Assessment Rating
Additional Comments or Observations
Should be Empty:

Rows	Available	Functional	Needs Maintenance
Angiography System	1	2	3
Patient Monitoring System	4	5	6
Defibrillator	7	8	9
Contrast Injector	10	11	12
Lead Aprons	13	14	15
Radiation Shields	16	17	18

Rows	Present	Certified	Not Present
Interventional Cardiologist	19	20	21
Cath Lab Nurse	22	23	24
Radiology Technician	25	26	27
Anesthesiologist	28	29	30

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