Title Page

  • Site conducted

  • Machine Serial Number

  • Conducted on

  • Auditor

  • Location of where audit was performed?

Equipment and Operator Overview

Equipment Information

  • Unit Make

  • Unit Model

  • CVA Unit Number

  • Unit Hours

  • Unit Hours Since Last Audit

  • Controller Type

Equipment Photos

  • Photo #1 Taken from open entry door looking into cab?

  • Photo #2 View of entire left side of unit (Booms racked if applicable)?

  • Photo #3 View of entire right side of unit (Booms racked if applicable)?

  • Photo #4 View of entire front of unit (Booms racked if applicable)?

  • Photo #5 View of entire rear of unit (Booms racked if applicable)?

Machine Location Information

  • Assigned CVA Agronomy Location

Operator Information

  • Name of Primary Operator

  • Name of Secondary Operator

  • Has this machine been operated by additional locations or operators

  • Additional Operator/Location
  • Name of Additional Operator(s)/Location(s)

Record Keeping

Record Keeping

  • Are Unit Service Records Available?

  • Is this unit accident free since last audit?

  • Is this unit free of any major repair costs since last audit?

  • Has unit received bi-annual pan testing?

Safety

First Aid / Emergency Equipment

  • First Aid Kit Present, Adequate, and Accessible?

  • Eye Wash Solution Present, Sealed, and Accessible?

  • Water and Supplies Available for Operator Decontamination?

Fire Extinguisher

  • Fire Extinguisher Adequate? (min. 5 lbs, readily accessible, in mounting bracket, properly charged)?

Seat and Seatbelt

  • Is operator seat and restraint systems fully functional?

Personal Protective Equipment

PPE

  • Adequate PPE? (Eye protection, gloves, and cover-all suit)

Equipment Inspection

Appearance & Cleanliness

  • Appearance and Cleanliness at time of inspection?

Cab & Chassis

  • Cleanliness of Inside Cab.

  • Is glass free of cracks in drivers operating view?

  • Lights functional (turn signals, brakes, flashers, and headlamps) ?

  • Battery Box / Cleanliness and Condition?

  • Is battery disconnect functional?

Engine & Drivetrain

  • Is last service date recorded in cab or on equipment?

  • Engine Appearance/Cleanliness?

  • Fuel System Free of Leaks (especially in the engine area)?

  • Engine bay free of Oil leaks?

  • Engine bay free of Coolant leaks?

  • Radiator/Cooler Cleanliness and Condition?

  • Hydraulic Site gauges indicate proper fluid level?

  • Tires in safe operating condition?

Chassis/Applicator

  • Condition of Grease Points at pivot points?

  • Product Compartment Cleanliness?

  • Does this machine have a boom system?

  • Condition of Boom?

Audit Certification

  • Additional Auditor Comments or Notes

  • Signature of Auditor

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.