Pediatric Exam Table Inspection Checklist
Use this checklist to inspect and document the condition, safety, cleanliness, and readiness of a pediatric exam table.
Inspection Details
Inspection Date
*
-
Month
-
Day
Year
Date
Inspector Name
*
Inspector Role/Title
*
Department/Clinic Name
*
Room/Location Identifier
*
Pediatric Exam Table Condition Checklist
Overall Table Availability
*
Available
Needs Attention
Out of Service
Stability
*
Pass
1
2
Fail
3
1 is Pass, 3 is Fail
Surface Cleanliness
*
Pass
1
2
Fail
3
1 is Pass, 3 is Fail
Upholstery / Padding Condition
*
Pass
1
2
Fail
3
1 is Pass, 3 is Fail
Frame / Legs Condition
*
Pass
1
2
Fail
3
1 is Pass, 3 is Fail
Wheels / Casters Condition
Pass
1
2
Fail
3
1 is Pass, 3 is Fail
Safety Straps / Rails and Accessories Condition
Pass
1
2
Fail
3
1 is Pass, 3 is Fail
Findings and Corrective Actions
Problems Found
*
Severity / Priority
*
Low
Medium
High
Critical
Corrective Action Required
*
Follow-up / Repair Target Date
-
Month
-
Day
Year
Date
Final Inspection Outcome
*
Please Select
Pass
Pass with Corrective Action
Fail
Submit Inspection
Should be Empty: