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PPL HSE / FM / CH / 01

Rev: 00

Emergency Eye Wash Shower Inspection Sheet


Dept. / Field / Location: ____________________

Date of Inspection: ____________

Location / ID # of EWS: ____________________


Y/
N/
NA

S#

Checks

Is the area surrounding the Eye Wash


Shower free of all obstructions?

Visible signage placed for identification?

Any electrical
surrounding?

If yes then electrical panel is covered with


plastic sheets?

Is the Eye Wash easily activated?

Is the shower is operative by chain /


pedestal?

Are the nozzles equipped with protected


covers?

Is the water flowing from both eyepieces?

Is the flow of water of equal height from both


eyepieces?

10

Is the flow of water clear?

11

Does the spray pattern delivers a steady


stream of water or is further divided?

12

Is water flow adequate upon 3 minutes


continuous operation?

13

Is the water temperature constant and tepid?

14

Does the water drains properly from the


basin sink?

15

Is base of the station clean and free from any


drain water?

17

Is there any structural corrosion?

18

Is there any leakage through piping / water


tank.

panel

present

in

Suggested Action

Action by

Target
date

near

Comments :

Prepared by : _________________
HSE Representative

Reviewed by : _____________________________
Dept. Head / Field / Location Incharge

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