Healthcare Facility Life Safety Survey Checklist Form
Complete this checklist to assess life safety compliance and readiness in healthcare facilities.
Facility Name
*
Survey Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surveyor Name
*
First Name
Last Name
Unit or Area Surveyed
*
Overall Life Safety Compliance Rating
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Fire Protection System Status
*
Fully operational
Partially operational
Not operational
Not present
Emergency Exit and Egress Conditions
*
Rows
Clear and unobstructed
Properly marked
Exit doors functional
Yes
1
2
3
No
4
5
6
N/A
7
8
9
Evacuation Procedure Readiness
*
Fully documented and staff trained
Partially documented/trained
Not documented or trained
Safety Equipment Availability
*
Fire extinguishers
First aid kits
Emergency lighting
Alarm systems
Other
Observed Deficiencies
Corrective Action Priority
*
Please Select
Immediate
High
Medium
Low
Submit Survey
Should be Empty: