Ultrasound Room Compliance Checklist Form
Use this form to document an ultrasound room compliance check, record readiness, and note any issues or corrective actions before or after use.
Room and Inspection Details
Ultrasound Room Identifier or Name
*
Department / Location
*
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspection Time
*
Hour Minutes
AM
PM
AM/PM Option
Inspector Name
*
Inspector Role / Title
*
Inspection Type / Shift Status
*
Routine Check
Pre-Use Check
Post-Use Check
Follow-Up Check
Equipment and Room Compliance Checklist
Ultrasound machine power/boot status
*
Compliant
Not compliant
Not applicable
Probe and cable condition
*
Compliant
Not compliant
Not applicable
Transducer cleanliness
*
Compliant
Not compliant
Not applicable
Ultrasound gel availability
*
Compliant
Not compliant
Not applicable
Monitor and image display functioning
*
Compliant
Not compliant
Not applicable
Printer, PACS, and network connectivity
Compliant
Not compliant
Not applicable
Exam bed condition
*
Compliant
Not compliant
Not applicable
Lighting condition
Compliant
Not compliant
Not applicable
Privacy curtains and doors
*
Compliant
Not compliant
Not applicable
Emergency and safety equipment presence
*
Rows
Present
Not present
Not applicable
Emergency call device
1
2
3
Fire extinguisher
4
5
6
First aid kit
7
8
9
Sharps container
10
11
12
Hand hygiene supplies
13
14
15
Infection Control and Supplies
Available cleaning supplies
*
Disinfectant wipes
Approved cleaning supplies
Other
Probe covers available if needed
*
Yes
No
Not applicable
Hand hygiene supplies present
*
Hand sanitizer
Soap
Paper towels
Other
Disposable paper or linens available
*
Disposable paper
Disposable linens
Other
Room cleanliness status
*
Clean
Needs cleaning
Not assessed
Supply shortages or infection-control issues observed
Issues, Corrective Actions, and Sign-Off
Issues Found / Non-Compliance Details
Corrective Actions Required / Completed
Priority / Severity
*
Low
Medium
High
Urgent
Final Status
*
Please Select
Compliant
Compliant with Issues
Not Compliant
Confirmation
*
I confirm the inspection information is accurate
Submit Checklist
Should be Empty: