Minimum Standards Checklist Form
Use this form to evaluate and document whether a site, process, item, or service meets the required minimum standards. Complete all checklist items and add follow-up actions as needed.
Checklist: Required Documentation is Present
*
Operating permits/licenses are displayed
Inspection logs are up to date
Safety protocols are posted
Checklist: Physical Environment Meets Standards
*
Cleanliness and order maintained
All equipment in working order
Emergency exits accessible
Checklist: Staff Training Requirements Met
*
Staff have completed required training
Training records are available
Checklist: Compliance with Safety Procedures
*
Personal protective equipment (PPE) is used
Incident reporting process is followed
Status of Minimum Standards
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Met
Partially Met
Not Met
Overall Compliance Rating
*
1
2
3
4
5
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name
*
First Name
Last Name
Summary of Non-Conformities
Recommended Follow-Up Actions
Submit Checklist
Should be Empty: