- Form Date*
- Reception / waiting area planned correctly?*
- Exam rooms included and appropriately sized?*
- Procedure / treatment rooms included and appropriately sized?*
- Clean utility room included?*
- Soiled utility room included?*
- Storage areas included and adequate?*
- Staff work area included and adequate?*
- Accessible restrooms included?*
- Corridors and egress routes compliant?*
- Support spaces included and planned correctly?*
- Equipment category / type
- Electrical capacity adequate*
- Emergency power available*
- Proper grounding confirmed*
- Medical gas needs identified*
- Ventilation and HVAC adequate*
- Lighting levels acceptable*
- Infection control surfaces suitable*
- Handwashing access available*
- Sharps and waste handling in place*
- Fire and life safety requirements met*
- Accessibility requirements addressed*
- Alarm and security considerations reviewed*
- Overall Review Status*
- Target Completion Date*
- Should be Empty: