Health Facility Supervision Checklist Form
Complete this checklist to assess operational and safety readiness during health facility supervision.
Facility Name or Identification
*
Date of Supervision
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Full Name
*
First Name
Last Name
Department or Area Inspected
*
Cleanliness and Hygiene
*
Satisfactory
Needs Improvement
Unsatisfactory
Equipment Functionality
*
All Functional
Some Issues
Major Issues
Emergency Preparedness (Supplies, Exits, Protocols)
*
Adequate
Partial
Inadequate
Staff Availability and Training
*
Sufficient & Trained
Partial
Insufficient
Key Findings or Observations
Corrective Actions and Follow-up Due Date
Rows
Corrective Action
Due Date
Action 1
Action 2
Action 3
Submit Checklist
Should be Empty: