• Conducted on

  • Employee being audited

  • Site Name

  • Location
  • Name of Customer Contact

  • Prepared by

Scope of Work

  • Scope of Work

  • Other SOW:

  • Ticket Number:


  • Was a EHS Survey / Project Safety Tailgate Meeting conducted? Is the form properly filled and available onsite

  • Did the Service Engineer (SE) receive instructions regarding evacuation in the event of an emergency

  • Does the SE know the onsite emergency phone number?

  • Does the SE know who the emergency contact is?

  • Does the SE know where the nearest hospital or burn center is?

  • If required by the Customer, did the SE use a Method of Procedure?

  • If provided by the customer, did the SE attend site-specific safety training?

  • What did it cover?

  • If required, has the arc flash boundary been delineated using a safety barricade or tape?<br>

  • Are MSDS's available for the materials being used on site?

  • Is there an ENP-company safety and environmental manual available on site?

  • Is the SE familiar with the Company work / rest notification rule?

  • How many hours on site?

  • How many hours of travel today?


  • Is the Service Engineer (SE) certified in First Aid, CPR and AED? ​ <br> First Aid Date________ CPR Date________<br>

  • First Aid Training Date

  • CPR Training Date

  • Is the SE’s carrying their current First Aid and CPR card, if appropriate?

  • Has the SE received Blood Borne Pathogens training? Training Date__________

  • BBP Training Date

  • Has the SE received PPE training?

  • PPE Training Date

  • Has the SE received Fall Protection training? Training Date_________

  • Fall Protection Training Date

  • Has the SE received LOTO training? Training Date_________

  • LOTO Training Date

  • Has the SE received Arc Flash Training? Training Date__________

  • Arc Flash Training Date

  • Has the SE received Confined Space Training? Training Date__________

  • Confined Space Training Date

  • Has the SE received Electrical Safety? Training Date__________

  • Electrical Safety Training Date

  • Has the SE received Fire Extinguisher or Fire Prevention training? ​ <br> Fire Extinguisher Training Date________Fire Prevention Training Date_________

  • Fire Extinguisher Training Date


  • Is the work site clean of trash, and maintained in an orderly manner?

  • Are Tripping Hazards identified and minimized?

  • Does the site contain potable drinking water?

  • Are chemicals/combustible liquids identified and stored properly?

  • Are appropriate fire extinguishers with current inspection tags available?


  • Does the Service Engineer (SE) have company issued hard hat and<br>safety glasses as required? ​ <br>

  • Is the SE wearing appropriate safety/work shoes?

  • Is the SE conforming to customer’s required specific PPE requirements?

  • Does the SE have an acid faceshield and apron, if required?

  • Are electrical gloves & sleeves inspected before use?

  • Are voltage insulating gloves marked with the current testing or MFG dates?

  • Glove Date

  • Glove photo

  • Are voltage insulating sleeves marked with current testing or MFG dates?

  • Sleeve Date?

  • Sleeve photo

  • Does the SE have all required Arc Flash ATPV cal/cm2 clothing and are <br>they wearing the appropriate Arc Flash ATPV cal/cm2 for all tasks? ​

  • Does the SE have Arc rated face shield and is it in good condition?

  • Does the SE have the appropriate arc rated hearing protection?

  • K. Do 3rd Party Service Providers working for our company have appropriate<br>PPE including arc flash protection? ​ <br>


  • If work in areas requiring fall protection are identified as a job requirement,<br>is the Service Engineer (SE) authorized to wear fall protection?​ <br>

  • If the work being performed requires fall protection, is the equipment available,has it been inspected prior to use, and is it being used correctly?

  • Where practical, are all SE’s using fall protection systems over 4 feet (1.2 m)?


  • If job-required, has the Services Engineer (SE) obtained a Hot Work Permit?

  • If hot work is required, did another SE performed Fire Watch duties?

  • Did the Fire Watch attend their post for at least 30 minutes after hot work?


  • Has the Service Engineer (SE) removed all jewelry before working on<br>energized equipment? ​ <br>

  • Has the Customer opened main breakers controlling equipment or wiring?

  • Have stored energy sources (capacitors, batteries, springs, charging mechanisms, moving machinery parts,<br>hydraulic systems, etc.) been properly discharged, blocked or released?​

  • Have energy sources (electrical & mechanical) been locked out and tagged?

  • Require a demonstration of LOTO…did SE perform the procedure correctly?

  • Has the SE tested the circuit being worked on to verify that it is at a zero energy<br>state (de-energized) using a company approved voltage detector?​​​ <br>

  • Meter Calibration Date

  • Meter Calibration Photo

  • Are electrical panels covered when not being worked on?

  • Is the SE using insulated battery mats if required?

  • Are extension cords in good condition and properly rated?

  • Has Customer provided a One Line diagram for the electrical distribution,<br>if requested?​

  • Does the SE know what the shock limited, restricted and prohibited approach<br>boundaries are, and does he understand their significance?​

  • Does the SE know what the Arc Flash, Limited Approach, Restricted Approach<br>and Prohibited Approach Boundaries are for the task and do they understand their significance?

  • Unless long tip probes are permitted by the business unit, are only only<br>short tip multimeter probes available for use?​

  • Does the SE have required company issued insulated tools?

  • Are insulated tools in good condition and free of nicks?


  • Have ladders been visually inspected and are they in good condition?

  • Are all ladders fiberglass and ANSI rated 1A (300 lbs/137 Kg) or 1AA (375 lbs/170 Kg)? OR<br>EN Class 131(150 Kg / 330 lbs), or Class 1 (175 Kg/385 lbs) maximum?​

  • If in use, have extension ladders been positioned so that the ratio of ladder height to distance from the wall / building is no greater than 4:1? ​


  • Proper Lifting – Back Straight; tested weight of unknown object before attempting to lift; No twisting at the hips; Lifting with Legs & buttocks; Feet offset for stability; Hug load to body.

  • Did the Service Engineer (SE) create a “clear path” before lift and carry?

  • Carry – 28 feet distance (8.5 m) @ 1 per 5 minutes < 26 lbs (12 Kg)?

  • Overhead – Not lifting objects >14 lbs (6.4 Kg), above 6’10” (2 m)?

  • If the company has established a maximum safe lifting limit, did the SE<br>understand and conform to the policy limit? ​


  • Is vehicle exterior clean and undamaged?

  • Is the windshield in good condition (no cracks, stars)?

  • Vehicle not leaking fluids (water, oil, antifreeze, fuel, etc.)?

  • All exterior lights functional?

  • Outside mirrors attached and adjustable?

  • Are tires in good good condition?


  • Is vehicle interior clean and undamaged?

  • Are dashboard gauges functioning and warning lights out?

  • Does vehicle’s horn sound?

  • Are all interior lights functioning?

  • Are the insurance, registration, and accident report forms readily available?

  • If applicable, are vehicle inspection records up to date?

  • Is the vehicle safety shield/cage installed?

  • Are seat belts and rear view mirror in good condition?


  • If required, is vehicle equipped with an appropriate Fire Extinguisher?

  • Is the monthly inspection record complete?

  • Does the vehicle contain a Spare Tire and Jack?

  • Does the Service Engineer (SE) have a current First Aid Kit?

  • Is the first aid kit completely stocked with required, unexpired supplies?

  • Is there a flashlight in the vehicle or in the SE’s toolkit?

  • If required, is the vehicle equipped with Reflective Safety Triangles or flares?


  • Overall Assessment

  • Is follow up necessary?<br>

  • By Whom?


  • 1.

  • 2.

  • 3.

  • 4.

  • 5.

  • 6.

Safety Survey Comments/Reccomendations


  • Auditor Signature

  • SE Signature

  • Service Manager/Supervisor Signature

Liebert Services

Cooling CE's

  • Is CE a Cooling CE?

  • Are Cooling CE"s wearing goggles during spray or brush cleaning?

  • Required Flares, Fire Extinguisher and Roadway Triangles in Vehicle?

  • Red (Acid) and Blue (Base) chemicals segregated in vehicle?

  • Flammable gasses (acetylene, MAPP) secured with multiple hold-downs?

  • Associates wearing No. 3 or 5 shade goggles when brazing or cutting metal?

Battery Safety

  • Does the Associate perform battery work?

  • Are CE's and Battery Specialists wearing gloves when making connections?<br>

  • Associate checking for Zero voltage each time before making connection?

  • Associate wearing goggles when taking hydrometer readings?

  • Associate wearing new arc flash apron for potential exposure to acid?

  • Associate wearing special battery shield (not arc flash shield) for acid?


  • Is a Respirator in use?

  • Are company issued respirators maintained in sanitary condition?

  • Require associate to perform pre-use inspection. Conforms to standard?

  • Unused detachable cartridges are in original sealed bags?

  • Detachable cartridges are disposed of after one use?

  • Demonstrate user seal checks? Did associate perform neg and pos test?

Control of Hazardous Energy (CoHE) Porcedures

  • Is Lockout Tag-out required to perform the scheduled service work?

  • Did Associate perform LOTO Correctly?

  • If No LOTO required the associate must verbally discuss how he would perform LOTO if it was required. Did the associate successfully demonstrate?

  • Did the associate check TKO to determine if there is a CoHE procedure?

  • Did the Associate use the Hazardous Energy Reference Table (HERT)?<br>

  • Where all COHE and HERT documents accurate?

Liebert Services Company Vehicle

  • Has the company vehicle been altered from the original issued state?

  • Install of Sound/Video or permanent GPS equipment?

  • Installation of Trailer Hitch?

  • Window Tinting?

  • Any other Alterations?

  • Inspect for GPS Jammer. Does the Associate have one?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.