Title Page
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Equipment Name
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Serial number/ model /make
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What is the classification of the activity performed?
- Inspection
- Maintenance/Calibration
- Repair
- Upgrades/Modifications
- Installation/Commissioning
- Decommissioning/Disposal
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If a contractor performed the maintenance, please provide their company name.
Safety
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Before starting maintenance check machine is operational, by running systems
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Check operation of all Emergency Stops
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Check operation of all Safety Guards and condition
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Check operation of all interlocking mechanisms
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Isolate Supplies where applicable
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POWER
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WATER
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HYDRAULICS
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AIR
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Lock out tag out applied ?
Maintenance Activity
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What is the date and time of the maintenance or calibration activity performed?
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What is the name of the person performing the maintenance or repair activity?
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Please provide a brief description of the work performed during the maintenance or calibration activity.
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Were any parts replaced during the maintenance or repair activity?
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Please list:
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Were any supplies used during the maintenance or repair activity?
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please list:
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Did the maintenance or repair activity include any equipment inspection or testing?
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Please attach relevant checklist(s) or report(s)
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Was there any deviations or issues identified during the inspection or testing?
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Please detail:
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Did the maintenance or repair activity result in any downtime for the equipment?
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Please provide the duration of the downtime.
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Were there any recommendations for future maintenance or calibration activities based on the results of the inspection or testing?
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Please detail:
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Are there any additional comments or observations you would like to include regarding the maintenance or calibration activity?
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Please provide additional comments or observations:
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Take or Attach Photos of Equipment
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Validated by:
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Next Maintenance Due on:
