UV Light Verification Checklist Form
Use this form to verify UV light setup, safety, and performance before or during use.
UV Light Setup and Identification
Date of Verification
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Verification
*
Hour Minutes
AM
PM
AM/PM Option
Location / Site or Room
*
Equipment or Unit Name / Identifier
*
UV Light Type or Model
*
Please Select
Handheld UV Lamp
Cabinet UV Light
Fixed UV Fixture
Portable UV Unit
Other
Verifier Name or Team
*
Pre-Use Safety and Readiness Checklist
Power source connected and stable
*
Checked
Housing/fixture intact
*
Checked
Guard/shield in place, if applicable
*
Checked
Warning labels visible
*
Checked
Area cleared of unauthorized persons
*
Checked
Eye/skin protection available, if required
*
Checked
Surrounding surfaces free of obvious hazards
*
Checked
UV Light Performance Verification
Power on test passed
*
Yes
No
Lamp/LED illumination observed
*
Yes
No
Intensity/brightness within acceptable range
*
Acceptable
Needs attention
Fail
Exposure distance or placement checked
Timer/shutoff function tested
Yes
No
Not applicable
Measurement reading captured
Inspection Findings and Corrective Actions
Deficiencies or Damage Observed
*
Corrective Action Required
*
Verification Result Status
*
Pass
Pass with Notes
Fail
Responsible Person for Follow-up
Target Completion Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: