Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • Field Service Engineer

  • Equipment

  • Others people present at audit

  • Tasks performed

  • Documentations

  • Document number

Opening meeting

  • Are there any follow-ups to the previous evaluation?

  • list which ones

6 Planning

6.1.1 General

  • Was maintenance or installation planned with the customer?

  • Have arrangements been made with the customer for the management of waste generated by Varian during maintenance or installation activity?

6.1.2. Hazard identification

  • Is Customer's Safety Plan present?

  • Is Customer's Emergency response present?

  • If there are other companies in the in the ward, did the Customer manage the interference risks?

7 Support

7.1 Resources

  • Does maintenance or installation activity require more than one FSE?

  • Specify the procedure

  • Does maintenance or installation activity require support from one or more suppliers?

  • Indicate the list of suppliers

7.3 Awareness

EHS aspects

    Worker(s)
  • FSE name:

  • If required, does the FSE have suitability for the job certificate (health check)?

  • Certificate due date

  • If required, is the FSE authorized to work in the presence of an electrical risk?

  • If required, does the FSE have the radiation safety training certificate?

  • Is the FSE aware of Customer's Safety Plan?

  • If required, does the FSE have emergency training certificate?

  • Is the FSE aware of EHS procedures?

  • Does FSE have the lock-out, tag-out?

  • Are tools in good condition (visually checked for damage, DVM , cables ...)?

  • Does FSE have the necessary PPE with him/her to perform the required tasks?

  • PPE and dosimeters present

  • Other PPE worn

  • EPD calibration date

  • Does the FSE have the latest procedures, iSIR updated?

  • Does the FSE know that he has to report incidents, near misses, and good observations using myCority and to the Site Manager?

7.4 Communication

  • Is the maintenance or installation plan present in Unity?

8 Operation

    8.1 Operational planning and control
  • Task assessed:

  • Risks present

  • Does FSE know how to handle Chemical / SDS-Location?

  • Is the lock-out and tag-out equipment at hand and does it demonstrate how to use it?

  • Does FSE follow the electrical safety procedure?

  • Does FSE properly verify the ladder before using it?

  • Does FSE use the ladder safely?

  • Are equipment parts (e.i. Couch or MLC or collimator) clean (no Blood Borne Pathogens are present)?

  • Disinfectant to clean is present

  • Disinfectant to clean is present

  • PPE and dosimeters worn

  • Other PPE worn

  • EPD calibration date

8.2 Emergency preparedness and response

  • Is the FSE aware of Customer's Emergency Response?

10 Improvement

  • List any findings / comments / corrective actions

Overall conclusion

  • Number of health and safety non-conformities

  • Number of environmental non-conformities

  • Overall conclusion

Signature

  • Auditor Signature

  • Audidee(s) Signature

  • Audidee(s) Signature

  • Audidee(s) Signature

  • Other person present at audit

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.