Playground Safety Assessment Form
Conduct a thorough evaluation of playground safety, equipment, and maintenance.
Playground Name or Location
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Full Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Playground Equipment Condition Checklist
*
Rows
Present and Intact
Needs Repair
Not Applicable
Swings
1
2
3
Slides
4
5
6
Climbing Structures
7
8
9
Seesaws
10
11
12
Merry-Go-Rounds
13
14
15
Other Equipment
16
17
18
Surface Condition and Safety
*
Surface is safe and well-maintained
Minor issues (e.g., unevenness, small debris)
Major hazards (e.g., exposed concrete, large debris)
Are there any visible hazards present? (e.g., broken glass, sharp objects, animal waste)
*
No hazards observed
Yes, minor hazards (specify below)
Yes, major hazards (specify below)
If hazards were observed, please specify the type and location
Maintenance Needs (select all that apply)
*
Cleaning required
Repairs needed
Replacement of equipment
No maintenance needed
Other (please specify)
Overall Playground Safety Rating
*
1
2
3
4
5
Additional Comments or Recommendations
Inspector Signature (draw your signature to confirm this assessment)
*
Submit Assessment
Submit Assessment
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