Instruction Record - Eyewash Weekly 15 Minute Flush Record DHS 4653

Eyewash Weekly “15 Minute” Flush Record / Instruction Record Office of Developmental Disabilities Stabilization and Crisis Unit 1. The eyewash station MUST have an unobstructed path, accessible within 10 seconds. 2. Water must flow for at least 15 minutes. Valves must remain open without the use of hands. 3. Eyewash must be clean, sanitary, and operating correctly. Month Week 1 Week 2 Week 3 Week 4 Week 5 Date Safety Rep. Date Safety Rep. Date Safety Rep. Date Safety Rep. Date Safety Rep. Decemb / / / / / / / / / / er January / / / / / / / / / / Februar / / / / / / / / / / y March / / / / / / / / / / April / / / / / / / / / / May / / / / / / / / / / June / / / / / / / / / / July / / / / / / / / / / August / / / / / / / / / / Septem / / / / / / / / / / ber October / / / / / / / / / / Novem / / / / / / / / / / ber Decemb / / / / / / / / / / er Location of eyewash The distance from the worker’s location to the device should not exceed 10 seconds walking distance. The determinant factor is immediate eye irrigation within 10 seconds. The path must be unobstructed and cannot require opening doors or passing through obstacles unless other employees are always present to help the exposed employee. Eyewash Weekly “15 Minute” Flush Record POST THIS ABOVE EYEWASH SINK for WEEKLY SIGN OFF DHS 4653 (08/14) Valve operation: Stay-open valves must be in place and be operable to allow an individual to use both hands to hold eyes open or remove clothing. Eye wash stations are to be readily available. Caps for stations must be used. Temperature: Elevated water temperatures may accelerate adverse chemical reactions.

Eyewash Weekly “15 Minute” Flush Record POST THIS ABOVE EYEWASH SINK for WEEKLY SIGN OFF DHS 4653 (08/14)