CLEARANCE TESTING AUDIT/ASSESSMENT FORM

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Contractor on site

SECTION 1. SITE DETAILS

• Audit Number

• Audit Title

• Site Address Being Audited
  Address

• Analyst Being Audited

  Select Simon Mitchell Lisa Worley

  • Simon Mitchell
  • Lisa Worley

• Date of Audit

  Date

• Location Air Monitoring Sampling

• Type of Air Monitoring

  Select 4 Stage Clearance Reassurance Leak Test Background Personal

  • 4 Stage Clearance
  • Reassurance
  • Leak Test
  • Background
  • Personal

• Site Job Number

SECTION 2. DOCUMENTATION CHECK

• Has the analyst reviewed the method statement, risk assessment, COSHH on site?

  Compliant

  Non-Compliant

  N/A

• Analysts guide HSG248 on site?

  Compliant

  Non-Compliant

  N/A

• Analyst company in-house procedures on site?

  Compliant

  Non-Compliant

  N/A

• Has a site specific risk assessment been carried out? (Check Analysts PDA)

  Compliant

  Non-Compliant

  N/A

SECTION 3. STAGE 1 Site Setup and Assessment

• Does the Analyst have all necessary equipment available

  Compliant

  Non-Compliant

  N/A

• Has the Analyst Checked Transit Route

  Compliant

  Non-Compliant

  N/A

• Has the Analyst inspected areas surrounding the - Enclosure,Van and Skip

  Compliant

  Non-Compliant

  N/A

• Has the Analyst inspected Enclosure,Vision Panel placement or CCTV

  Compliant

  Non-Compliant

  N/A

• Has the Analyst checked the DCU

  Compliant

  Non-Compliant

  N/A

• Has the Analyst inspected contractors on site decontamination equipment

  Compliant

  Non-Compliant

  N/A

• Has Analyst taken sufficient amount of photographs?

  Compliant

  Non-Compliant

  N/A

SECTION 4. STAGE 2 Visual Inspection

• Is the analyst wearing app appropriate PPE/RPE?

  Compliant

  Non-Compliant

  N/A

• Does the Analyst have all the necessary equipment ( Torch,Flexible Mirror,Screwdriver,Wet Wipes and Camera)

  Compliant

  Non-Compliant

  N/A

• Has the Analyst witnessed the Site Supervisor conduct visual inspection?

  Compliant

  Non-Compliant

  N/A

• Has the analysts inspected enclosure and air locks for debris

  Compliant

  Non-Compliant

  N/A

• Has the Analyst checked surfaces of remaining plant/equipment in the Enclosure? (Use of Wet Wipes or Visual)

  Compliant

  Non-Compliant

  N/A

• Has the analyst recorded findings to wether enclosure is dry?

  Compliant

  Non-Compliant

  N/A

• Has the analyst inspected integrity of Enclosure?

  Compliant

  Non-Compliant

  N/A

• Did the Analyst conduct the visual inspection for the recommended length of time? (Record Time)

  Select Compliant Non-Compliant N/A

  • Compliant
  • Non-Compliant
  • N/A

• Has Analyst taken sufficient amount of photographs?

  Compliant

  Non-Compliant

  N/A

• When the analyst left the enclosure after Stage 2 have they carried out the correct decontamination procedure?

  Compliant

  Non-Compliant

  N/A

SECTION 5. EQUIPMENT SETUP AND CHECKS

• Is the equipment in use calibrated, labelled and in good order?

  Compliant

  Non-Compliant

  N/A

• Has the Analyst allowed the Air Sampling pump to stabilise?

  Compliant

  Non-Compliant

  N/A

• Has the Analyst calibrated the flow meter using the master flowmeter

  Compliant

  Non-Compliant

  N/A

• Has the Analyst checked the Flow rate to ensure the correct amount of air is being pulled through the pump

  Compliant

  Non-Compliant

  N/A

• Has the Analyst started the calibrated timepiece to record pump run?

  Compliant

  Non-Compliant

  N/A

SECTION 6. CALIBRATED EQUIPMENT

• Microscope (serviced) - Ref I.D

• In Calibration?

  Yes

  No

  N/A

• Stage Micrometer - Ref I.D

• In Calibration?

  Yes

  No

  N/A

• NPL test slide - Ref I.D

• In Calibration?

  Yes

  No

  N/A

• High Flow Meter - Ref I.D

• In Calibration?

  Yes

  No

  N/A

• Low Flow Meter - Ref I.D

• In Calibration?

  Yes

  No

  N/A

• Tally Counters - Ref I.D

• In Calibration?

  Yes

  No

  N/A

• Barometer - Ref I.D

• In Calibration?

  Yes

  No

  N/A

• Thermometer - Ref I.D

• In Calibration?

  Yes

  No

  N/A

• Timer - Ref I.D

• In Calibration?

  Yes

  No

  N/A

SECTION 7. NON CALIBRATED EQUIPMENT

• Does all relevant equipment have a valid PAT test?

  Compliant

  Non-Compliant

  N/A

• Does the analyst have an adequate number of high flow pumps to carry out suitable air monitoring?

  Compliant

  Non-Compliant

  N/A

• Does the analyst have a low flow (personal) pump?

  Compliant

  Non-Compliant

  N/A

• Does the analyst have and adequate number of cowl heads to carry out suitable air monitoring?

  Compliant

  Non-Compliant

  N/A

• Does the analyst have an acetone vaporiser?

  Compliant

  Non-Compliant

  N/A

• Does the analyst have a calculator?

  Compliant

  Non-Compliant

  N/A

• Does the analyst have adequate supplies of slides, cover lips and filters?

  Compliant

  Non-Compliant

  N/A

• Does the analyst have spare equipment in case of emergencies? (Fuses 3A/13A, bulbs, mask filters?)

  Compliant

  Non-Compliant

  N/A

• Does the analyst have sufficient acetone/triacetin?

  Compliant

  Non-Compliant

  N/A

SECTION 8. STAGE 3 Air Sampling

• Is the analyst wearing app appropriate PPE/RPE?

  Compliant

  Non-Compliant

  N/A

• Has the Analyst confirmed NPU is capped and switched off?

  Compliant

  Non-Compliant

  N/A

• Has the analyst removed all non essential work items from the enclosure?

  Compliant

  Non-Compliant

  N/A

• Has the Analyst placed the correct number of pumps in relation to the enclosure size?

  Compliant

  Non-Compliant

  N/A

• Has a disturbance been carried out using a brush? (1.5 minutes per pump up to a max of 5 mins)

  Compliant

  Non-Compliant

  N/A

• Has the Analyst confirmed the full run time and the flow rate has been maintained?

  Compliant

  Non-Compliant

  N/A

• When the analyst left the enclosure after Stage 3 have they carried out the correct decontamination procedure?

  Compliant

  Non-Compliant

  N/A

SECTION 9. STAGE 4 Enclosure Dismantling

• Has the Analyst witnessed the Dismantling of the Enclosure.

  Compliant

  Non-Compliant

  N/A

• Has the Analyst checked the area to ensure it is free of debris after dismantling?

  Compliant

  Non-Compliant

  N/A

• Has the Analyst checked waste routes and areas surrounding skips and vans?

  Compliant

  Non-Compliant

  N/A

• Has the Air Test Interface been complete in full on the PDA?

  Compliant

  Non-Compliant

  N/A

• Has the Certificate of Reoccupation been filled out correctly (Calculations and all entries need to be checked)

  Compliant

  Non-Compliant

  N/A

• Has the analyst took sufficient amount of photographs?

  Compliant

  Non-Compliant

  N/A

SECTION 10. DCU CLEARANCE

• Has the Analyst checked the DCU to ensure contractor has cleaned prior to Air Clearance?

  Compliant

  Non-Compliant

  N/A

• Has the Analyst carried out the correct number of sample to the DCU (<10m2 = 1 - >10m2 = 2)

  Compliant

  Non-Compliant

  N/A

• Has the Analyst carried out the equipment checks as section 5

  Compliant

  Non-Compliant

  N/A

Q.C.

• Have the correct version of forms been used? (Check version on document index)

  Compliant

  Non-Compliant

  N/A

Auditor Sign Off

• Assessment/Audit Satisfactory

  Yes

  No

  N/A

• Analyst Approved?

  Yes

  No

  N/A

• Specify date of re-assessment

  Date

• Note: if no then document details of discussion/training that has taken place.

• Comments

• Any comments, Is there requirements for the analyst to be retrained in any areas?

• Auditor Signature

  Sign

• Analyst Signature

  Sign