Emergency Preparedness

Appendix D.4 –Hazard Surveillance Form

Kern Medical Emergency Preparedness

Emergency Operations Plan

Appendix D.2: MANAGEMENT OF ENVIRONMENT

HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM

Date:______________________________ Building:______________________________

Program

Hazard Surveillance/Risk Assessment Item 1 2 3 4 5

Comments

1. Are grounds clean & free of hazards? 2. Are floors clean, dry, in good repair, & free of obstruction? 3. Are mechanisms for access (i.e. ramps, handrails, door opening mechanisms, etc.) operational? 4. Is the parking area free of potholes or other hazards? 1. Are doors functioning & locked as appropriate? 2. Are medical records centrally located and accessible ONLY to authorized personnel? 3. Are alarms functioning, tested, and maintained in accordance with manufacturer's specifications? 4. Are systems/mechanisms in place to quickly notify officials or other staff quickly in the event of a security related problem? SUBTOTALS 1. Are OSHA Hazard Communication and Exposure Control Documents Available? SUBTOTALS

Safety Management

PROGRAM TOTAL:

Security Management

PROGRAM TOTAL:

Hazardous

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