Internal EMS Audit

Audit Plan Worksheet

Scheduled Audit Date:
Auditors:

Audit Location:

Primary Procedure/Document?
No
Document Name: _________________
Document ID: ____________________

Yes (If yes, the following information is required.)

Owner: _________________________
Revision #: ______________________

Pre-Audit Preparation
Support Documentation Reviewed:

Follow-up Issues from previous audits:

Audit Plan
Positions to Interview:

Item/Issue: ________________________________________________________
Notes: ___________________________________________________________
_________________________________________________________________
Item/Issue: ________________________________________________________
Notes: ___________________________________________________________
_________________________________________________________________
Item/Issue: ________________________________________________________
Notes: ___________________________________________________________

Form #: EMS-0101.011B
Effective Date: 2-14-2001
Revision Date: 2-14-2001
Revision #: 0

Record ID #: EMS-0101.011B-______-______
Corresponding Procedure: EMS-0100.011
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