Have you or a loved one been a patient of Patriot? Please let us know how it went! Patient Survey Transport survey Your Name (optional) First Name Last Name Date of Transport * MM DD YYYY Name of crew member(s) * How would you rate our service? Customer Service * Poor Fair Good Excellent Professionalism * Poor Fair Good Excellent Bedside Manners * Poor Fair Good Excellent Timeliness * Poor Fair Good Excellent Text Area Thank you! Patriot Monthly Station Inspection Checklist Inspection List Station Inspection Checklist Exterior Premises Sidewalks clear and free of slip/trip hazards. Yes No N/A Parking area clear of slip/trip hazards. Yes No N/A Exterior lighting in place and working. Yes No N/A Storage areas neat, clean and secure. Yes No N/A General Building Condition Aisles and walkways clear of obstructions and trip hazards. Yes No N/A Stairs clear of obstructions and trip hazards Yes No N/A Doorways clear of obstructions and trip hazards Yes No N/A All doors open fully and easily. Yes No N/A Electrical outlets and extension cords not overloaded. Yes No N/A All electrical cords intact with no worn areas. Yes No N/A All power and equipment cords are secured out of the way of workers. Yes No N/A All lights in working condition. Yes No N/A Kitchen clean and fume hood filter clean. Yes No N/A Laundry facilities clean, working with no dirt buildup behind and lint trap clean. Yes No N/A All office chairs stable and working. Yes No N/A Filing cabinets are stable and marked with signs instructing users to open only one drawer at a time and close when not in use. Yes No N/A Safety/Training Board info current with old removed. Yes No N/A Fire/Life Safety All exits properly marked and lights working. Yes No N/A All doors not an exit, marked "Not an Exit". Yes No N/A Evacuation routes posted by doors in all rooms. Yes No N/A Date of last evacuation drill? MM DD YYYY Emergency lighting systems working. (30 second test) Yes No N/A Carbon monoxide detectors tested and working. Yes No N/A Alarm systems including detectors tested and working. Yes No N/A All means of egress clear of clutter. Yes No N/A All doors open fully and easily. Yes No N/A All fire extinguishers fully charged and free of corrosion. MM DD YYYY Furnace and AC units checked and filters clean. Yes No N/A Other Eyewash station -clean, check and refill (change every three months). MM DD YYYY Indoor storage areas neat, clean and clutter free. Yes No N/A All secondary containers are properly labeled with hazards identified. Yes No N/A Bay floors clean, dry and free of slip/trip hazards. Yes No N/A All chemical products in approved containers. Yes No N/A All ladders are clean, working properly and stored safely. Yes No N/A All unit disinfection logs are complete and turned in to be filed. Yes No N/A Deficiencies Noted Corrective actions taken. Coordinator signature Manager signature Your feedback has been sumbitted. Thank you!
