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Eyewash/Safety Shower Inspection
Monthly Inspection per ANSI Z358.1
30-DAY INSPECTION TRACKING
💧
ANSI Z358.1 requires weekly activation tests and annual comprehensive inspections. This monthly inspection supplements those requirements.
📋
Inspection Information
Inspector Name
*
Date
*
District / Base
*
Select District / Base...
Unit TBD
Other
🚿
Station Information
Equipment Type
*
Select Type...
Combination Eyewash/Shower
Eyewash Station Only
Safety Shower Only
Portable Eyewash
Drench Hose
Eye/Face Wash
Station Number / ID
*
Take photo of the station ID tag
No tag on this item
Get close so the station ID tag fills the photo. The photo is saved with this inspection as evidence.
Check History
Specific Location
Manufacturer
Model
Water Temp (°F)
✓
Inspection Checklist
Accessibility & Signage
Section N/A
Location clearly identified with signage
Pass
Fail
N/A
Path to unit is unobstructed
Pass
Fail
N/A
Unit accessible within 10 seconds
Pass
Fail
N/A
Area well-lit
Pass
Fail
N/A
Floor area around unit is clear
Pass
Fail
N/A
Eyewash Components
Section N/A
Dust covers in place (if equipped)
Pass
Fail
N/A
Nozzles clean and free of debris
Pass
Fail
N/A
Heads align properly for eye flushing
Pass
Fail
N/A
Activation mechanism works smoothly
Pass
Fail
N/A
Stays-open valve functions properly
Pass
Fail
N/A
Flow pattern adequate for flushing
Pass
Fail
N/A
Shower Components (if equipped)
Section N/A
Shower head clean and unobstructed
Pass
Fail
N/A
Pull rod/handle operates freely
Pass
Fail
N/A
Stays-open valve functions
Pass
Fail
N/A
Adequate water coverage pattern
Pass
Fail
N/A
Drain functioning properly
Pass
Fail
N/A
Water Quality & Flow
Section N/A
Water flows immediately on activation
Pass
Fail
N/A
Water is clear (no discoloration)
Pass
Fail
N/A
No unusual odor in water
Pass
Fail
N/A
Water temperature tepid (60-100°F)
Pass
Fail
N/A
Adequate flow rate maintained
Pass
Fail
N/A
Portable Units Only
Section N/A
Solution level adequate
Pass
Fail
N/A
Solution not expired
Pass
Fail
N/A
Unit sealed/tamper indicator intact
Pass
Fail
N/A
General Condition
Section N/A
No visible corrosion or damage
Pass
Fail
N/A
Piping connections secure
Pass
Fail
N/A
Unit stable and properly mounted
Pass
Fail
N/A
Inspection tag current
Pass
Fail
N/A
📊
Overall Result
Inspection Result
*
Pass - Operational
Fail - Needs Repair
Out of Service
📝
Findings & Actions
Deficiencies Found
Corrective Actions
✅ Submit Eyewash/Shower Inspection
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