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.