Printable eyewash & emergency shower inspection log
Run each eyewash and drench shower and record the weekly activation check.
Print this and fill it in by hand. Nothing is saved and nothing is sent — this page keeps no record of anything.
Eyewash & emergency shower inspection log
Blank form · complimaint.com
Facility
Building / area
Month & year
Completed by
- 1Reachable and unobstructed
- 2Identified by a sign, and the area is lit
- 3Activates and stays on hands-free
- 4Flushing fluid flows from both heads / the shower head
- 5Water runs clear after the dead-leg is flushed
- 6Protective caps or covers in place and undamaged
- 7Unit undamaged — no leaks, no corrosion, nothing missing
- 8Drainage or run-off does not create a hazard
Type: Plumbed eyewash · Self-contained (portable) eyewash · Eye/face wash · Emergency shower · Combination shower and eyewash · Drench hose · Other
| Date | Station ID | Location | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | By | Notes / action taken |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
Mark each numbered column P (pass), N (needs attention) or — (not applicable). Anything marked N belongs in the notes column with what was done about it.
A blank form to fill in by hand. It records what you observed. It does not state how often you are required to do this, and it does not decide whether a reading or a finding is acceptable — those come from your own policy, your equipment manufacturer, and the authority having jurisdiction.
What the interactive version adds
Keeps your station inventory between visits, files the record against your facility, and shows the regulation and the consensus standard apart instead of printing one under the other's heading.
Eyewash Station & Emergency Shower Inspection Log — free, no signup, and it stays on your device like everything else here.
What is on this sheet
Before the first row the sheet asks for facility, building / area, month & year, and completed by — the four or five facts that make a loose page findable a year later, when the question is not what the reading was but which building and which month it came from.
The grid is 14 rows, each one station, walked against every question. What it asks for that no other form here asks for is station id; the rest — date, location, by, and notes / action taken — is the same on every blank form in this catalog, because those are the columns that make a row attributable.
The numbered columns are not headings but a legend: 8 questions asked of every station, printed once above the grid and numbered to match, which is the only way 8 of them fit across a page. They are reachable and unobstructed, identified by a sign, and the area is lit, activates and stays on hands-free, flushing fluid flows from both heads / the shower head, water runs clear after the dead-leg is flushed, protective caps or covers in place and undamaged, unit undamaged — no leaks, no corrosion, nothing missing, and drainage or run-off does not create a hazard.
The type legend prints plumbed eyewash, self-contained (portable) eyewash, eye/face wash, emergency shower, combination shower and eyewash, drench hose, and other, so a row can say what kind of thing it is without a second column for it.
A completed sheet is a record of an inspection: every station activated, checked and dated. It is a record of what somebody observed and nothing more. It does not say how often you are required to do this, and it does not decide whether a reading or a finding is acceptable — those come from your own policy, your equipment manufacturer, and the authority having jurisdiction.