EYE WASH BOTTLE CHECK SHEET

CHECK POINTS

BOTTLE BASE DRAIN TUBE EYE CUP PERFORATED PLATE

S.NO UNIT SERIAL NO
PRESENT
PRESENT & NO PRESENT & PRESENT & NO
& NO
DAMAGE NO DAMAGE DAMAGE
DAMAGE

10

11

12
CK SHEET
HECK POINTS
CAPTIVE SNAP-
ON CAP
CHECKED CHECKED
REMARKS
PRESENT & NO DATE BY
DAMAGE
 EYE WASH BOTTLE CHECK SHEET
S.NO UNIT SERIAL NO REMARKS
1

10

11

12
 EYE WASH STAND CHECK SHEET
S.NO CHECK POINTS GOOD CONDITION WEEK 1 WEEK 2 WEEK 3
1 VISIBLE INDICATION PRESENT & NO DAMAGE

2 NO OBSTRUCTION TO ACCESS CLEAR ACCESS

3 WATER FLOW FROM NOZZLE FREE & EQUAL HEIGHT & FLOW

4 WATER FLOW CHECK (15MINS) CONTINUOUS FLOW

5 WATER CONDITION NO DIRTY WATER

CHECKED DATE

CHECKED BY

REMARKS
WEEK 4