EmailMeForm
Self Inspection - West District
Please fill out the form and click "Submit" at the end.
Lodge Information
Please enter your Lodge and requested contact info below
Your Lodge
Select Your Lodge
Buckeye #2686
Gila Bend #2089
Lake Havasu City #2399
Parker #1929
Phoenix #335
Phoenix West #2729
Raceway #2852
Scottsdale #2148
Sun City #2559
Wickenburg #2160
Yuma #476
Date
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MM
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DD
/
YYYY
Name
*
First
Last
Email
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Access Roads, Walkways, & Parking Areas
Free of debris, cracks, & broken paving
YES
NO
N/A
Different elevations between adjacent walkways provided with guards or well marked
YES
NO
N/A
Walkways flat, well drained, & without holes
YES
NO
N/A
Fences & barricades secured & in good condition
YES
NO
N/A
Pathways & parking areas well lighted
YES
NO
N/A
Walkways have safe clearance from motorized equiptment
YES
NO
N/A
Signs indicating "Park at Your Own Risk"
YES
NO
N/A
Stairs & Ramps
Standard stair rails or handrails provided on stairways with four or more stairs & ramps
YES
NO
N/A
Handrails well secured with no sharp or rough parts
YES
NO
N/A
Stair tread & riser free of chips, cracks, & uneveness
YES
NO
N/A
Stair treads & ramps slip resistent
YES
NO
N/A
Stairways & ramps well lighted
YES
NO
N/A
Do stairs have at least 6½' overhead clearance?
YES
NO
N/A
Elevators/lifts inspected as required by local law?
YES
NO
N/A
Floor & Wall Openings
Large glass areas subject to human impact well marked
YES
NO
N/A
Floor opening provided with guard rail or cover
YES
NO
N/A
Grate type covers designed not to affect foot traffic
YES
NO
N/A
Safe floors - Non Skid
YES
NO
N/A
Exiting & Egress
Emergency lighting provided in corridors & stairways
YES
NO
N/A
All exits marked & properly illuminated
YES
NO
N/A
All doors, passages, & stairs that aren't exits properly marked
YES
NO
N/A
All exits & passageways free of obstructions
YES
NO
N/A
There are at least 2 means of egress provided from upper floors
YES
NO
N/A
Exit Doors
All exit doors opening the direction of exit
YES
NO
N/A
Cold storage room doors provided with inside release
YES
NO
N/A
Doors opening into street provided with warnings or barriers to prevent stepping into path of vehicles
YES
NO
N/A
Doors opening into street provided with warnings or barriers to prevent stepping into path of vehicles
YES
NO
N/A
Storage Areas
Storage areas clean, dry, & free of refuse
YES
NO
N/A
Entrance to area lock when unattended
YES
NO
N/A
Flammables & combustibles stored away from heating devices & open flames
YES
NO
N/A
Trash & debris in metal covered containers & regularly removed
YES
NO
N/A
Emergency & First Aid
Emergency numbers posted at each phone
YES
NO
N/A
Employees instructed on reporting emergencies
YES
NO
N/A
Employees instructed on use of portable exstinguishers
YES
NO
N/A
First aid kits clean & fully stocked
YES
NO
N/A
Outdoor Fixtures & Playgrounds
Benches & tables free of cracks, slivers, & broken parts
YES
NO
N/A
Water fountain & taps in good repair without broken parts
YES
NO
N/A
BBQ free of sharp edges & have no missing parts
YES
NO
N/A
Playground equipment clean & in good repair
YES
NO
N/A
Swimming Pool
Appropriate caution signs posted
YES
NO
N/A
Proper enclosure to prevent falling into pool or access to children
YES
NO
N/A
Glass cups & plates not allowed in pool area
YES
NO
N/A
Remove diving board
YES
NO
N/A
Certified Lifeguard on duty when pool is open
YES
NO
N/A
Kitchen, Bar, & Restaurant
Metal container with cover provided for greasy rags
YES
NO
N/A
Knives stored in holders when not in use
YES
NO
N/A
Electrical cords & plugs of appliances in good condition
YES
NO
N/A
Food processing equipment properly guarded & in good repair
YES
NO
N/A
Glass stored away from open ice storage & food storage areas
YES
NO
N/A
Gas & beverage concentrate cylinders secured against tipping
YES
NO
N/A
Drain & other floor openings covered
YES
NO
N/A
Non-skid mats provided in line of sinks, ice machine, range, etc...
YES
NO
N/A
Are mats clean, & without grease or other build-up?
YES
NO
N/A
Foods stored off the floor
YES
NO
N/A
Food covered & stored in refrigerator when not being prepared. Proper temperatures being maintained.
YES
NO
N/A
Hoods & filters over range clean & not laden with grease
YES
NO
N/A
Suppression system in hood(s) inspected in the last 6 months
YES
NO
N/A
Chairs, stools, & tables in good condition
YES
NO
N/A
Board of Health certified server and inspection
YES
NO
N/A
Restrooms, Locker Rooms, Showers, & Saunas
Maintained dry, clean, sanitized & free of debris
YES
NO
N/A
Well illuminated, burned out bulbs promptly replaced
YES
NO
N/A
Hand towel, soap, toilet paper, & sink fixtures secured & in good repair
YES
NO
N/A
Toilet stall & locker walls, doors, & latches secure & in good repair
YES
NO
N/A
Walking surfaces of non-skid materials
YES
NO
N/A
Appropriate warning signs posted, e.g. "CAUTION-SLIPPERY WHEN WET" / "DO NOT USE FOR MORE THAN 15 MINUTES", etc...
YES
NO
N/A
Personal Protection Devices
Appropriate protective devices provided for chemicals on site such as respirators for gas leaks, gloves, goggles, etc...
YES
NO
N/A
Compliance with "Right to Know" requirements where applicable
YES
NO
N/A
Protection Devices
All automatic fire sprinkler system supply valves wide open
YES
NO
N/A
All heat/smoke detection systems in operation
YES
NO
N/A
Portable extinguishers serviced in last 12 months & tagged
YES
NO
N/A
Pressures in appropriate range on gauge
YES
NO
N/A
Extinguishers properly mounted at stations
YES
NO
N/A
Extinguishers recharged as required
YES
NO
N/A
All sleeping quarters provided with smoke detectors unless provided with automatic sprinklers and carbon monoxide detectors
YES
NO
N/A
Optional Notes
Add anything you deem prudent here in this field
