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Weekly and quarterly eyewash and safety shower compliance record
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Inspection Items
Circle or mark the applicable column for each item: P = Pass | F = Fail | N/A = Not applicable. Record notes for any F.
| # | Check | P | F | N/A | Notes / Action |
|---|---|---|---|---|---|
| Location & Accessibility | |||||
| 1 | Location: station is in its designated position and clearly visible | ||||
| 2 | Access path: unobstructed within 10 seconds travel from hazard area | ||||
| 3 | Signage: eyewash sign is visible, legible and illuminated (if required) | ||||
| 4 | Floor area: clear, non-slip, no trip hazards around station | ||||
| Water Flow & Delivery | |||||
| 5 | Activation: valve or lever operates with one hand in one second or less | ||||
| 6 | Flow: both nozzles deliver a steady, even stream to both eyes | ||||
| 7 | Flow duration: station maintains continuous flow for at least 15 minutes | ||||
| 8 | Stay-open valve: once activated, valve remains open without hand pressure | ||||
| 9 | Water supply: connected, no leaks in plumbing or supply line | ||||
| Water Quality & Temperature | |||||
| 10 | Clarity: water runs clear, no discolouration or sediment | ||||
| 11 | Temperature: tepid water between 16 °C and 38 °C (per AS 4775) | ||||
| 12 | Odour: no unusual smell indicating contamination or stagnation | ||||
| 13 | Flushing: weekly flush completed to prevent bacterial growth (date recorded) | ||||
| # | Check | P | F | N/A | Notes / Action |
|---|---|---|---|---|---|
| Physical Condition & Cleanliness | |||||
| 14 | Nozzle covers: dust caps in place and intact (removed easily) | ||||
| 15 | Nozzles: clean, free of debris, corrosion or mineral build-up | ||||
| 16 | Bowl / basin: clean, draining correctly, no blockage | ||||
| 17 | Body / frame: no cracks, rust, damage or loose mounting | ||||
| 18 | Drain: outlet clear and connected to waste or appropriate drainage | ||||
| Self-Contained Units (if applicable) | |||||
| 19 | Fluid level: reservoir is full to required level | ||||
| 20 | Expiry date: solution is within shelf life, not expired | ||||
| 21 | Seal: tamper seal intact (if fitted) | ||||
| Compliance & Documentation | |||||
| 22 | Inspection tag: current tag attached with last inspection date recorded | ||||
| 23 | AS 4775 compliance: station meets Australian Standard requirements | ||||
| 24 | Operating instructions: posted near station and legible | ||||
Defects & Action Required (list any item marked F: reference item # from checklist)
| Item # | Defect description | Action taken / reported to | Rectified by / date |
|---|---|---|---|
Declaration
I declare that I have completed this eyewash station inspection. I have reported any defects or non-compliant items. Any station found to be non-functional, contaminated or non-compliant with AS 4775 has been reported to the responsible person and will not remain in service until rectified.