Restroom Assessment Checklist

*Please fill in ALL the fields

1. Name (please denote Mr/Ms/Mrs/Dr)
   
   
   
   
2. Contact Number
   
   
   
   
3. Email Address
   
   
   
   
4. Date of Assessment (DD/MM/YYYY E.g. 01/01/2010)
   
   
   
   
5. Time of Assessment (HH:MMam/pm E.g. 12:00pm / 12:00am)
   
   
   
   
6. Address of Assessment
   
   
   
   
   ENTRANCE
   
   
7. There are prominent signages and the entrance looks clean
   
   Yes
   No
   
   
   HAND WASH AREA
   
   
8. All the taps at the basin and hand dryers are in working condition
   
   Yes
   No
   
   
9. The hand soap dispensers are filled and in working condition
   
   Yes
   No
   
   
10. Overall, the hand wash area is clean and tidy, with no litter
    
    Yes
    No
    
    
    WATER CLOSET (WC) AREA
    
    
11. The cubicle door is clean and free of graffiti
    
    Yes
    No
    
    
12. The door lock and coat hook are intact and functional
    
    Yes
    No
    
    
13. The toilet bowl seat and cover/squat pan is intact and stain free
    
    Yes
    No
    
    
14. The WC flush/sensor flush is functional and free of dust and stain
    
    Yes
    No
    
    
15. The toilet paper dispenser is intact and functional with toilet paper
    
    Yes
    No
    
    
16. Sanitary bin (for ladies only, one in each cubicle) is clean, intact and lined with plastic bag
    
    Yes
    No
    
    
    URINALS (FOR GENTS ONLY)
    
    
17. The urinals are intact and functional without chokage
    
    Yes
    No
    
    
18. The urinal flush/ sensor flush is functional and free of dust and stain
    
    Yes
    No
    
    
    GENERAL AREAS
    
    
19. The floor, walls, wall tiles and ceiling are free from dust, stains and litter
    
    Yes
    No
    
    
20. The lightings are intact and functional, and of appropriate brightness
    
    Yes
    No
    
    
21. The toilet is odour free and the floor is dry
    
    Yes
    No
    
    
22. Are there any other areas to improve on? (Please key in N/A if no improvements)
    
    
    
    
23. Any other comments? (Please key in N/A if no comments)
    
    
    
    

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