The purpose of the Inspection Checklist is to document and verify equipment safety and
operation. The checklist presented is for demonstration purposes only and should be
modified to meet the requirements of a business. If an inspector finds that a piece of
equipment is out of compliance, the actions required to resolve the issues should be
documented in the recommendations section and signed-off by the appropriate
individuals. This form contains standard language commonly use in this type of form,
however, this form should be modified to fit the needs of the user. Small businesses
can use this form to verify equipment safety.
Inspection Checklist
Equipment: _________________________________ Date: _______________________
Equipment Location: _________________________
Checklist Yes No Action Required
Walking Surfaces
1. Are floors and aisles clear of tripping hazards? __X___ _____
2. Is there adequate drainage to collect liquid
__X___ _____
discharge from the equipment?
3. Is non-slip surface coating applied around the Install non-slip coating in
_____ __X___
equipment? front of stairway
4. ________________________________ _____ _____
Equipment Guarding
1. Is the equipment securely anchored? __X___ _____
2. Are the rotating parts, pulleys, belts, etc. guarded? __X___ _____
3. ________________________________ _____ _____
Equipment Shutdown
Apply yellow reflective
adhesive around the
1. Is the electrical power shutdown clearly marked? _____ __X___
shutdown box and install
an “Emergency Stop” sign
2. Is there an adequate number of properly located
__X___ _____
manual reset emergency stops?
3. Have maintenance employees been trained in the
equipment-specific shutdown and chemical __X___ _____
handling procedures?
4. ________________________________ _____ _____
Electrical
1. Is all conduit, cable, and wire properly attached? ___X__ _____
2. Is there evidence of fraying electrical cords? _____ __X___
3. Are switches mounted in clean, tightly closed
___X__ _____
metal boxes?
© Copyright 2011 Docstoc Inc. 2
Recommendations:
To prevent the risk of falling, a non-slip coating needs to be installed in front of the equipment
stairway.
The electrical power shutdown switch is not clearly marked and could prevent a rapid shutdown
of the equipment in the case of an emergency.
These repairs must be complete by 12/05/2011, and a re-inspection will be scheduled for
12/06/2011.
Inspected by: Approved by:
(Signature) (Signature)
© Copyright 2011 Docstoc Inc. 3
INFORMATION AND FORMS ARE PROVIDED "AS IS" WITHOUT ANY EXPRESS OR IMPLIED WARRANTY OF ANY KIND
INCLUDING WARRANTIES OF MERCHANTABILITY, NONINFRINGEMENT OF INTELLECTUAL PROPERTY, OR FITNESS
FOR ANY PARTICULAR PURPOSE. IN NO EVENT SHALL DOCSTOC, INC., OR ITS AGENTS, OFFICERS, ATTORNEYS,
ETC., BE LIABLE FOR ANY DAMAGES WHATSOEVER (INCLUDING, WITHOUT LIMITATION, DAMAGES FOR LOSS OF
PROFITS, BUSINESS INTERRUPTION, LOSS OF INFORMATION) ARISING OUT OF THE USE OF OR INABILITY TO USE
THE MATERIALS, EVEN IF DOCSTOC HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. They are for
guidance and should be modified by you or your attorney to meet your specific needs and the laws of your state or jurisdiction. Use at
your own risk. Docstoc® is NOT providing legal or any other kind of advice and is not creating or entering into an Attorney-Client
relationship. The information, reports, and forms are not a substitute for the advice of your own attorney. The law is a personal matter
and no general information or forms or like the kind Docstoc provides can always correctly fit every circumstance.
Note: Carefully read and follow the Instructions and Comments contained in this document for your customization to suit your specific
circumstances and requirements. You will want to delete the Instructions and Comments from open bracket (“[“) to close bracket (“]”)
after reading and following them. You (or your attorney) may want to make additional modifications to meet your specific needs and the
laws of your state. The Instructions and Comments are not a substitute for the advice of your own attorney.
◊ Where within this document you see this symbol: ◊ or an instruction states “Insert any number you choose◊,” or something similar, or
there is a blank for the user to complete, please note that although Docstoc believes the information or number may be any that the user
chooses, and that there is no law governing what the informatio