Emergency Eyewash Shower Station Weekly Activation Log
Mandated compliance verification per ANSI Z358.1-2014 Section 5.5.2 & WorkSafeBC OHS Regulation Part 33.4. This form documents the mandatory weekly activation test to ensure adequate flushing fluid supply, proper flow rate, and mechanical function of emergency eyewash and shower equipment.
Pursuant to ANSI Z358.1-2014, emergency eyewash and shower equipment must be activated weekly to verify proper operation, ensure flushing fluid is available (tepid, potable), and clear the supply line of sediment and microbial growth. This log serves as a legally defensible record of compliance. Failure to maintain this log can result in OHS fines and liability in the event of a safety incident.
This test must be performed on every installed unit within the facility. Documentation must be kept for a minimum of 3 years per standard record-keeping practices.
- Chemical Exposure / Secondary Injury: Stagnant water poses a risk of microbial contamination (Pseudomonas, Legionella). Weekly activation purges standing water. Verify anti-scalding bypass valve operation before initiating test.
- Required Personal Protective Equipment: Operator conducting the test must wear suitable chemical-resistant gloves, face shield, and apron appropriate for the highest hazard chemical present in the immediate work area. Ensure activation test does not create a slip hazard on the floor.
- Isolation / Tag-out: Confirm that the unit is NOT locked out for maintenance and that the supply valve is fully open. If unit is out of service, a temporary barrier and highly visible signage must be installed.
Audit / Inspection Matrix
| Status (P/F) | Checklist Item / Hazard | Compliance Standard | Action Required / Notes |
|---|---|---|---|
| [ ] P [ ] F | Flow Rate Verification — Activate eyewash and shower simultaneously. Eyewash must deliver ≥ 0.4 GPM. Shower must deliver ≥ 20 GPM. | ANSI Z358.1 5.4.4 / 4.1.2 | _________________________ |
| [ ] P [ ] F | Flushing Fluid Temperature — Verify fluid temperature is tepid (60°F – 100°F / 15.6°C – 37.8°C) using a calibrated thermometer. | ANSI Z358.1 5.5.6 | _________________________ |
| [ ] P [ ] F | Signage & Accessibility — Ensure unit is unobstructed, path is clear, and highly visible sign is present within 10 ft (3 m). | ANSI Z358.1 6.1.1 / 6.3 | _________________________ |
| [ ] P [ ] F | Mechanical Function — Operate all valves to verify smooth actuation. Check for leaks at all connection points. | ANSI Z358.1 5.5.2 | _________________________ |
| [ ] P [ ] F | Flushing Fluid Quality — Inspect fluid for discoloration, particulates, or odour. Ensure dust covers are intact and clean. | ANSI Z358.1 5.1.3 | _________________________ |
Incident / Corrective Action Log
| Date / Time | Unit # | Safety Issue Identified | Corrective Action Taken | Assigned To |
|---|---|---|---|---|
| ___/___/_____ ___ : ___ | _______ | _______________________________ | _______________________________ | _______ |
| ___/___/_____ ___ : ___ | _______ | _______________________________ | _______________________________ | _______ |
| ___/___/_____ ___ : ___ | _______ | _______________________________ | _______________________________ | _______ |
I hereby certify that the weekly activation tests have been performed on all designated emergency equipment listed above, that all equipment is operating within ANSI Z358.1-2014 specifications, and that any deficiencies noted have been documented and corrective action initiated.