Business Contamination Assessment Checklist Form
Use this form to assess contamination risks, document affected areas, and record follow-up actions for a business site. Provide accurate details so the assessment can be reviewed and acted on consistently.
Business Overview
Business name
*
Business type / industry
*
Please Select
Retail
Food service
Manufacturing
Healthcare
Office
Warehousing
Construction
Hospitality
Transportation
Other
Site / location being assessed
*
Assessment date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor name or role
*
Contamination Assessment
Contamination sources present
*
Dust
Mold
Water intrusion
Pests
Chemical residue
Food residue
Oil/grease buildup
Soot/smoke residue
Standing water
Visible debris
Other
Affected areas
*
Entrance/Reception
Storage area
Production area
Kitchen/Food prep area
Restrooms
Office spaces
HVAC/Ventilation
Loading dock
Waste disposal area
Equipment/machinery
Inventory/stock room
Other
Severity rating
*
1
2
3
4
5
Immediate action needed
*
None
Monitor
Clean
Isolate
Escalate
Follow-up and Notes
Corrective Action Notes or Observations
Priority Level for Follow-up
*
Low
Medium
High
Final Assessment Summary / Next-Step Recommendation
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