Title Page

  • Service Org

  • Conducted on

  • Inspected by

  • Customer's Name

  • Location of activity inspected
  • Select the type(s) of activity being inspected

  • Short description of activity being inspected

  • Staff inspected (name & role)

  • Provide pictures of the working environment(s) and product(s) being worked on

    1. Please answer "Compliant", "Non-Compliant" or "N/A" (not applicable or not inspected) to all questions below.
    2. Add photos and notes by clicking on the paperclip icon (can also be good practices) - Suggest action if immediate action is not sufficient
    3. For deviations observed, specify in the text description if the situation is categorized as a Severe Observation (SO) or if immediate action is sufficient
    4. Complete audit by providing digital signature
    5. Share your report by exporting as PDF, list findings and any further actions required on the Observation / Suggestion tracking file

    Severe Observation (SO) – Deviation with a high potential to immediately cause a severe incident (refer to MESH Element 10 for definition). In case of SO the activity must be stopped for further investigation.

EHS Policies

  • EMEA/local Service EHS Procedures

  • EHS Incident, Near-Miss and Observation Reporting

  • Life Saving Rules Policy

  • Right to Refuse Policy

  • ‘Stop, Stand Back and Get Help’ Policy

  • ‘Take 5 for Safety’ Policy

  • Country/Site Drugs, Alcohol and Smoking Policy

  • Country Working Hours Policy

  • Lone Working Policy

  • Cold/Heat Stress Management

  • Mobile Phone Policy

  • Site Emergency Response Procedures

EHS Procedures requirements

  • Job Safety Review

  • Risk Control Plan

  • Pre-Job Check

  • Point of Work Risk Assessment

  • Arc-Flash Assessment

  • Justification for Energized Electrical Work

  • Authorized Routine Energized Electrical Work

  • Energized Electrical Work Permit

  • Documented Briefing to Working Party for Live Electrical Work

  • Lockout-Tagout (LOTO)

  • Customer Permit-to-Work

  • Knowledge of Field Service Bulletin for product being worked on

  • Knowledge of User / Service Manual(s) relevant for the activity

EHS Competencies requirements

  • Qualified Electrical Worker Level

  • First Aid / CPR /AED

  • LoTo

  • Powered Industrial Truck Driver

  • Site EHS Induction

  • Hazardous Substances

  • Confined Space Entry

  • Working at Height

  • Understanding of electrical installation/system

Electrical Safety

  • Is this section fully/partially applicable?

  • Barricades used to restrict access to the work area when performing work on exposed energized electrical parts?

  • Competent stand-by person available during electrical work outside the barricade?

  • Absence of conductive tools and equipment (incl. jewellery and other articles such as prescription eye glasses)?

  • Use of calibrated voltage reading meter for determining absence of voltage?

  • Any remaining live parts prevented from getting contact with?

  • Pre-use check and suitable PPE worn when exposed to electrical shock and/or arc-flash?

Fall Protection / Working at height

  • Is this section fully/partially applicable?

  • Hierarchy of controls applied (eliminate, prevent, minimize)?

  • Fall arrest equipment used when employees are working at elevations greater than 1.8 meters?

  • Pre-use checks performed on fall arrest equipment or other working at height equipment?

  • Use non-conductive portable ladders?

  • Fall arrest protection equipment undergoes a documented inspection at least quarterly?

  • Scaffolding being used erected for intended use, in good conditions and equipped with green tag following weekly inspection?

Confined Spaces

  • Is this section fully/partially applicable?

  • Valid and accurate Permit-to-Work been issued?

  • Works performed according to PTW content?

  • CS atmosphere tested for oxygen and potential hazardous gases?

  • Standby person available and rescue plan in place?

Lockout / Tagout

  • Is this section fully/partially applicable?

  • Hazardous energy physically isolated from equipment to be worked on using suitable energy isolation device?

  • Locks placed by each member of the working party on each energy isolating devices (or suitable group lockout in place)?

  • Locks utilized for safeguarding works are red and have only one key?

  • Tag with name, contact details and ‘Do Not Operate’ text affixed to each lock?

  • Stored energy release and verification steps of LoTo process suitably performed?

  • Suitable process in place for lock transition?

Powered Industrial Trucks

  • Is this section fully/partially applicable?

  • PIT in good condition (incl. due date for inspection)?

  • Pre-use inspection conducted by PIT operator?

  • Restraint systems incl. seat belts utilized by PIT operator?

  • Safe loading and driving practice?

Other PPE

  • Suitable PPE for head and face protection?

  • Suitable PPE for hand protection?

  • Suitable PPE for foot protection?

  • Suitable PPE for breathing protection?

  • Suitable PPE for hearing protection?

  • Suitable PPE for body protection?

Workplace Access and Environment

  • Safe access walkway to the workplace?

  • Walking and working surface in good condition at the workplace, with satisfactory housekeeping level?

  • Walkways are properly separated from vehicle routes?

  • Identification and warning signs used for all hazardous areas in the vicinity?

  • Sufficient lighting at the workplace and for the task?

  • Physical risks being controlled (noise, vibration, radiations, heat/cold…)?

Product, tools and equipment

  • Product being worked on in good conditions?

  • Tools and equipment (incl. leads, cables and extension cords) in good conditions?

  • Tools and equipment duly inspected (incl. pre-use check)?

  • Tools and equipment suitable for the task?

Lifting, manual handling and postures

  • Safe mechanical lifting technique and planning?

  • Safe manual handling technique and planning?

  • All staff in healthy/ergonomic posture?

  • All staff in safe position (not in in hazardous location or line of fire)?

Hazardous substances and Environment

  • Is this section fully/partially applicable?

  • All persons that handle/use hazardous substance(s) aware about associated hazards?

  • Containers of hazardous substances in good condition and labelled, without risk for soil/water contamination?

  • Material Safety Data Sheet available and accurate?

  • Wastes properly segregated and disposed of?

Emergency Response

  • Access to relevant emergency response means (incl. phone, extinguisher and electrical rescue) and escape routes free from obstacles?

  • Automatic fire suppression systems using hazardous gases put in manual mode only (unless visual and audible alarm available and temporization allowing safe evacuation)?


  • Any other unsafe situation / behaviour observed? (not falling into one of the above categories - use notes to describe)

Good Practice

  • Any good practice identified? (use notes to describe)


  • Inspected by

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.