🚿 Emergency Eyewash Station Inspection

Monthly Equipment Safety Inspection

⚠️ OSHA 29 CFR 1910.151(c) & ANSI Z358.1-2014 Compliant | Monthly Inspection Required

📋 Station & Inspector Information

Inspector Name *

Inspection Date *

Company *

Location *

Specific Location (Building/Area) *

Station ID / Tag Number *

Station Type *

Water Source *

Combination Unit with Shower?

Manufacturer

Install Date

Last Annual Certification

🚶 Accessibility & Location

ℹ️ ANSI Z358.1 requires eyewash stations to be within 10 seconds (55 feet) travel distance from hazard, on same level, and free of obstructions.

Accessible & Unobstructed

Within 10 Seconds of Hazard

Signage Visible & Correct

💧 Water Flow & Quality

🚨 CRITICAL: Water must be tepid (60-100°F / 16-38°C) and flow for minimum 15 minutes. Weekly flushing required for plumbed units.

Activation Tested

Water Flow Adequate (0.4 GPM min)

Both Nozzles Flow Equally

Water Temp Tepid (60-100°F)

Flushed Minimum 3 Minutes

🔧 Components & Condition

Nozzle Covers Present

Dust Covers Functional

Basin/Bowl Clean

No Algae or Contamination

Drain Functional

Valves Operate Properly

Stay-Open Valve Works

Piping Condition

📄 Documentation & Certification

Inspection Tag Present

Inspection Tag Current

Annual Certification Current

🧴 Portable/Self-Contained Units (If Applicable)

ℹ️ Complete this section only for portable eyewash stations, gravity-fed tanks, or bottled solutions.

Portable Tank Full

Solution Not Expired

✅ Overall Condition & Inspection Result

Overall Station Condition *

Inspection Result *

✅ Pass❌ Fail - Tag Out of Service

Next Inspection Due

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