All About Air Electrical Safety Circuit, PLC or Control Circuit Modification Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Job Number

• Job Number

Safety Circuit Modification

• Reason for change to Safety Circuit

• Has a Risk Assessment been carried out on the machine or plant?

  Yes

  No

  N/A

• Does the Risk Assessment confirm the need for changes to the safety circuit?

  Yes

  No

  N/A

• What safety category has been determined from the risk assessment?

• Has approval been authorised by site manager or their representative and/ or Hitech QTP

  Yes

  No

  N/A

• Authorised by

  Sign

• Detailed description of work being carried out

• Has functionality test of changes that have been made been carried out?

  Yes

  No

  N/A

• Has integrity of the rest of the safety circuit been carried out to make sure applied changes haven't affected any other part of the circuit?

  Yes

  No

  N/A

• Have changes been tested and a test sheet completed for the job?

  Yes

  No

  N/A

• Have the changes that have been carried out satisfied the requirements of the safety category as prescribed in the risk assessment?

  Yes

  No

  N/A

• How were the changes made to the safety circuit verified to comply with the requirements of the safety category as prescribed in the risk assessment?

• Have all modifications been documented and drawings updated? Please attach to this form.

  Yes

  No

  N/A

PLC Modification

• Reason for change to PLC Program

• Are the changes to the PLC Program operational (affect the way the machine or plant works) or peripheral (changes to data tables, recipes or data collection)?

• Has a Risk Assessment been carried out on the machine or plant?

  Yes

  No

  N/A

• Does the Risk Assessment confirm the need for changes to the PLC Program?

  Yes

  No

  N/A

• Has approval been authorised by site manager or their representative and/ or Hitech QTP

  Yes

  No

  N/A

• Authorised by

  Sign

• Detailed description of work being carried out

• Has functionality test of changes that have been made been carried out?

  Yes

  No

  N/A

• Has integrity of the rest of the PLC program been carried out to make sure applied changes haven't affected any other part of the program and therefore changed the operation of the machine or plant?

  Yes

  No

  N/A

• Name of the Plant?

• Name of the PLC Program

• Ladder(s) and Rung(s) where changes were made?

• Description of the changes that have been made

• Add any relevant pictures

  Media

• Have changes been tested the program saved and dated?

  Yes

  No

  N/A

• Have any I/O modifications been documented and drawings updated? Please attach to this form.

  Yes

  No

  N/A

Control Circuit Modification

• Reason for change to Control Circuit

• Has a Risk Assessment been carried out on the machine or plant?

  Yes

  No

  N/A

• Does the Risk Assessment confirm the need for changes to the Control Circuit?

  Yes

  No

  N/A

• Has approval been authorised by site manager or their representative and/ or Hitech QTP

  Yes

  No

  N/A

• Authorised by

  Sign

• Detailed description of work being carried out

• Has functionality test of changes that have been made been carried out?

  Yes

  No

  N/A

• Has integrity of the rest of the Control Circuit been carried out to make sure applied changes haven't affected any other part of the program and therefore changed the operation of the machine or plant?

  Yes

  No

  N/A

• Have changes been tested and a test sheet completed for the job?

  Yes

  No

  N/A

• Name of the Plant?

• Have all modifications been documented and drawings updated? Please attach to this form.

  Yes

  No

  N/A

General Checks

• Visual Inspection

  Pass

  Fail

• Operational Test

  Pass

  Fail

Any Sketches, Pictures or Notes

• Sketches for Report

  Drawing

• Pictures for Report

  Media

• Notes

Sign Off

• Completed By

  Sign

• Electrical Worker in Charge

  Sign