Eye Wash Inspection Checklist Form
Complete this form to document the routine inspection of an eyewash station. Ensure all items are checked for safety compliance.
Station Identification Number
*
Station 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
*
First Name
Last Name
Is the eyewash station easily accessible?
*
Yes
No
Are the spray heads and covers clean and in good condition?
*
Yes
No
Is water flow steady and sufficient?
*
Yes
No
Is the water clear and at a safe temperature?
*
Yes
No
Are any corrective actions required? If yes, describe.
Submit Inspection
Should be Empty: