Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
To be completed when undertaking site surveillance of equipment condition and effectiveness of maintenance or renewals activity. Complete each section as applicable and sign and date at bottom. Use additional sheets if needed.
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Name
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Date
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Location
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Detail of Equipment / Completed work being inspected / Purpose
Immediate Observations - 1. Maintenance completed to acceptable standard
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Is the access secure and in good condition? ~Is the site access sufficient for plant delivery? ~Is the Access gate lockable with a functioning Lock & chain.
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Is the equipment housing secure?<br>-if Appropriate
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Is there visible evidence of maintenance activity having been carried out? <br>-Cleaned, greased, refilled, tidy, signed for etc
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Are equipment maintenance records available, completed as necessary? -Maintenance cards
- Compliant
- Non Compliant
- NA
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Is there evidence/record of adjustment? <br>-Where Necessary
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Is the standard of the maintenance consistence with the last maintenance date?
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Is the equipment PAT tested? - In date?
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Last Maintenance by (if Known)? -ATW Evidence
2. Equipment / Site Conditions
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Is the general condition of Equipment/Site Conditions<br>~Is there an sign of malfunction, cracks or damage to the equipment?
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Are diagrams and/or documentation required on site? <br>- Does the equipment have the necessary diagrams such as lift charts, HAVs record sheets etc to support the equipment?
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Has the necessary housekeeping of site been completed?<br>-De-veg for access, floor clean for REB etc.<br>
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Are any spares on site stored correctly and secured as necessary?
3. Unsafe Conditions or Acts
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Did you observe/note any unsafe acts or conditions<br>-if so, provide details. Has the unsafe act(s) been corrected? If not, stop the act and raise and action!
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Did you observe/note any unsafe acts or conditions<br>-if so, provide details. Has the unsafe act(s) been corrected? If not, stop the act and raise and action!
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Did you observe/note any unsafe acts or conditions<br>-if so, provide details. Has the unsafe act(s) been corrected? If not, stop the act and raise and action!
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Did you observe/note any unsafe acts or conditions<br>-if so, provide details. Has the unsafe act(s) been corrected? If not, stop the act and raise and action!
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Overall summary of findings
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Authority to Work - Competence Criteria Observed (add observed record and employee name and Applicable Criteria)
ACTIONS
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Detail of action to be taken
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By Who
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Date
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Signed
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Print Name
