Outpatient Facility Compliance Checklist Form

Outpatient Facility Compliance Checklist Form
Complete this form to assess the readiness of an outpatient facility for compliance inspection. Ensure all sections are reviewed thoroughly.
Facility Name
Facility Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Inspection Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Inspector Name
First NameLast Name
Is the facility clean and well-maintained?
Are emergency exits accessible and clearly marked?
Staff Credentials and Training
Rows Credentials Verified Training Up to Date
Medical Staff
Nursing Staff
Support Staff
Are medical records properly maintained and secured?
Rate the overall emergency preparedness of the facility.
Additional Comments or Observations
Should be Empty:

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