UNITED EO/EG III PROJECT

EYE WASH STATION MONTHLY CHECK LIST

LOCATION: EYE WASH NO: MONTH: YEAR:
st
NO CHECKING DETAILS 1 Week 2nd Week rd
3 Week 4th Week 5th Week
1 CONTAINER INSIDE WASHED AND FILLED FRESH WATER

2 EYE WASH CONTAINER OUT SIDE IS CLEAN AND STRATEGICALLY LOCATED.

3 WATER HOSE AND NOZZLE ARE CLEAN AND NOT EXPIRED?

4 EYE WASH STATION PROTECTED FROM DIRECT SUN LIGHT.

5 WATER CONTAINER SEAL IS GOOD CONDITION AND SECURED.

6 EYE WASH STATION AREA IS CLEAN AND TIDY.

7 ANY SIGNS OF DAMAGE ON WATER CONTAINER?

8 ANY SIGNS OF DAMAGE ON WATER HOSE AND NOZZLE?

9 ANY INTERRUPTION OR OVER FLOW DURING WASHING TIME?

10 EYE WASH STATION FREE FROM ANY OBSTRUCTION.

11 EYE WASH STAND, LABEL & SIGNAGE ARE IN GOOD CONDITION
WITNESSED
INSPECTOR NAME
JOB TITLE NAME & JOB TITLE
& SIGNATURE:
SIGNATURE:

DATE INSPECTED: EMPLOYEE I.D.# EMPLOYEE I.D.#

Indications: Good Condition , Poor Condition × and if any damage/defect / unsafe condition is found, immediately report to area S/V.