• Department / Area

  • Machine # and Name

  • Document No.

  • Conducted on

  • Prepared by

  • Reason for audit?


  • Pictures of machine or equipment

Action items

  • Machine is positioned correctly?

  • Anchored to floor?

  • Walls or fencing around machine are positioned correctly?

  • All Machine guards in place?

  • Light curtains in place and working correctly?

  • Pressure sensitive safety mats working correctly?

  • E-STOP's working correctly?

  • LOTO procedures posted on the machine?

  • PPE sign is posted?

  • Area free from Slip, Trip & Fall hazards?

  • Anti-Fatigue mats in place for operator?

Corrective Action

  • For any item marked "NO", IMMEDIATE corrective action must be taken before machine is put into service. Details below.

  • For any item marked "Needed", corrective action will be taken, however, machine can still be placed into service. Details below.


  • Maintenance signature

  • Supervisor or Lead signature

  • Plant Manager signature

  • EHS Manager signature

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.