Healthcare Facility Risk Assessment Form

Healthcare Facility Risk Assessment Form
Evaluate safety, compliance, and operational risks within your healthcare facility.
Facility Name*
Facility Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Assessment Date*
MonthDayYear
Date
Assessor's Full Name*
First NameLast Name
Assessor's Email Address*
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Risk Area Evaluation*

Rows	Compliant	Partially Compliant	Non-Compliant	Not Applicable
Fire Safety
Infection Control
Medical Equipment Safety
Electrical Safety
Hazardous Materials Handling
Patient Privacy & Confidentiality
Emergency Preparedness
Staff Training & Competency