This is University of Mass, Amherst's weekly emergency eyewash station inspection checklist. Great example of the simplicity of a form you can use for your own documented station checks and flushes.

1. Date Initials DateDate Date DateInitials Initials Initials Initials
Please flush eyewash sta�ons(s) weekly and check for the following:
Is the water clear?
Are the jets working properly?
Is the area around the sta�on clear of obstruc�ons?
Is there a bucket located under the eyewash to collect the run off?
Are they leaking?
Contact the Physical Plant service desk at 413-545-6401 or submit a work order
request at: h�p://www.umass.edu/facili�es/requests to repair the unit.
In an emergency, hold eyes open and flush for at least 15 minutes.
Call 911 and state location as UMass or UMPD at 413-545-3111.
Seek medical attention after use.
Any ques�ons, contact EHS at 413-545-2682 or askehs@umass.edu.
Emergency Eyewash Sta�on
Weekly Inspec�on Checklist