Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Field Service Engineer (FSE)
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Equipment
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Others people present at audit
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Tasks performed
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Documentations
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Document number
1) EHS Documents
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a) Is the Health & Safety documentation in place and signed by Varian and Customer (PSC, POS, DUVRI)?
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Which ones? Select them from the drop-down menu
- DUVRI
- Informativa rischi introdotti ex art 26
- Riunioni di cooperazione e coordinamento ex art.26
- Coordinamento delle misure di radioprotezione ex art 112 -113 d.gls 101/2020
- PSC
- POS
- Altra documentazione H&S predisposta dal committente
- None of the above
2) Site
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a) Are conditions for workers and pedestrian safe (construction site only)?
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b) Is there a Customer manager present (supervisor, health physicist, physician etc.)?
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c) Is access to the Bunker (vault) safe (construction site only)?
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d) Are toilets available and in good condition?
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e) Are the environmental conditions acceptable (temperature, light, humidity, noise, dust, etc.)?
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f) Is the Customer's safety signage present?
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g) Is the bunker (with the exception of working materials) tidy? Does it present no slip, trip or fall hazards?
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h) Is the equipment clean? Particularly on the couch and/or collimator, are there no biological fluids present?
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i) Are equipment warning signs present?
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l) Is LOTO present on the site?
3) Interference risks
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a) Is there only Varian staff in the work area?
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Has the presence of personnel from other companies been assessed in the Customer's safety document (PSC or DUVRI)?
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Which ones? Select them from the drop-down menu
- DUVRI
- PSC
- Verbali riunione di cooperazione e coordinamento
- EHS-03-P05-M10-Rev 01 Verbale di coordinamento
- Other
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b) Has the work area been secured to prevent access by patients or Customer personnel by adding safety signage at the bunker entrance and/or console area?<br>
4) Worker(s)
- Worker(s)
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Field Service Engineer (FSE) name:
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a) Is the FSE aware of EHS procedures?
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Does he know where they are located?
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Check the FSE's awareness of EHS procedures by interviewing him/her on 1 or 2 present in the drop-down menu.
- EHS-03-P01-Sorveglianza sanitaria e radioprotezione
- EHS-03-P04-D01-Materiale di consumo e attrezzature di lavoro
- EHS-03-P04-Acquisti
- EHS-03-P05-Gestione delle attività in appalto
- EHS-03-P07-Gestione rifiuti
- EHS-03-P08-Rev 08-Gestione Infortuni-NMGO-NC
- EHS-03-P13-Sorveglianza Fisica e Sanitaria della Protezione
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b) Does FSE have with him the suitability to work as category B radiation worker?
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c) Does FSE have with him the Company badge with photo?
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d) Are the tools in good condition (visually checked for damage, DVM , cables ...)?
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e) Does FSE have all required PPE to perform the planned activities?
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Which ones? Select them from the drop-down menu
- Safety shoes EN 345 (S1P)
- Electrical safety gloves CEI-EN 60903 Class 00
- Mechanical gloves EN 388
- Chemical/biological gloves EN 374 (nitrile)
- Chemical gloves EN 374 abc (polyethylene)
- Safety glasses EN 166
- Semi-Mask EN 149 - FFP2
- Semi-Mask with filters EN 149 - A2P2
- Ear plug EN 352.2
- Helmet
- Dosimeter whole body
- Dosimeter extremity
- Electronic Personal Dosimeter ( EPD)
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Are the available PPE in good condition?
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f) Is FSE aware of the Customer's emergency procedures?
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g) Does FSE have replicated iSIR in the last 15 days?
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h) Is FSE aware of the proper handling of replaced broken parts (EHS-03-P07)?
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i) Is FSE aware of the proper handling of replaced activated components (RMT0604G10 and EHS-03-P07)?
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l) Is FSE aware of how to report a Good Observation, Near Miss or Injury?
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Does FSE know how to access Cority?
5) Task assessed
- Task assessed
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Task assessed:
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What risks does the FSE face during this specific task? Select them from the drop-down menu
- Electrical risk
- Using ladder
- Chemical risk
- Mechanical risk
- Radiation safety
- Biological hazard
- Slip, trip and fall
- Manual handling heavy parts
- Lifting and lowering and carrying operations
- Other risks
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Does FSE know how to handle properly Chemical and know where SDSs are located?
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Does the FSE demonstrate how to use the LOTO correctly?
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Does the FSE follow the electrical safety procedure during this task?
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Does FSE check the ladder before using it?
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Does FSE use the ladder safely?
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Does the FSE check for biological fluids in the couch or collimator before starting activities?
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If necessary, does the FSE have with him a disinfectant to clean the Linac parts?
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Which ones? Select it from the drop-down menu
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Add risk(s) not listed in the drop-down menu
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What PPE and dosimeters does the FSE wear? Select them from the drop-down menu
- Safety shoes EN 345 (S1P)
- Electrical safety gloves CEI-EN 60903 Class 00
- Mechanical gloves EN 388
- Chemical/biological gloves EN 374 (nitrile)
- Chemical gloves EN 374 abc (polyethylene)
- Safety glasses EN 166
- Semi-Mask EN 149 - FFP2
- Semi-Mask with filters EN 149 - A2P2
- Ear plug EN 352.2
- Helmet
- Dosimeter whole body
- Dosimeter extremity
- Electronic Personal Dosimeter ( EPD)
7) Environment
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a) If necessary, is there a temporary place to stock the wastes?
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b) Is there an agreement with the customer for proper handling of used lead-acid batteries?
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c) If necessary, have SF6 gas bottles been properly stored by the Customer?
8) Company car
- Company car
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a) Is the FSE aware of Company Car coverage / maintenance (company car only)? Select from the drop-down menu the checks performed
- Winter tyres
- Summer tyres
- High visibility vest
- Maintenance
- Emergency triangle
- Failed
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b) Is the First aid kit present?
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Due date
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c) If present, are pressurized cans (WD 40, Triflow, compressed air, etc) stored properly by FSE?
09) Evaluation of EHS training effectiveness
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a) Hands-on test on the correct use of category 3 PPE. Select at least one from the drop-down menu
- Electrical safety gloves
- Half-mask (with filters A2P2)
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Did the FSE properly check the electric safety gloves before using them?
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Did the FSE wear the half mask (with A2P2 filters) correctly before using it?
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b) Interview the FSE on one or more of these specific risks: e.g., electrical hazard, use of a ladder, chemical hazard, or other hazards present during the audit.
10) Findings - Comments - Corrective Actions
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List any findings / comments / corrective actions
11) Overall conclusion
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Number of health and safety non-conformities
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Number of environmental non-conformities
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Overall conclusion
11) Signature
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Auditor Signature
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Audidee(s) Signature
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Other person present at audit
