Title Page
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Date & Time
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Shift
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Prepared by
Machine Safety Scan
Items to observe
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Any unguarded gears, sprockets, pulleys, or flywheels?
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Describe observation
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Photograph of unguarded gears, sprockets, pulleys, or flywheels
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Any exposed set screws, keyways, collars, etc.?
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Describe observation
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Photograph of set screws, keyways, collars, etc.
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Any bodily exposure to other dangerous moving parts?
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Describe observation
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Photograph of bodily exposure to other dangerous moving parts
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Any part of employee observed inside machine without equipment locked out?
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Describe observation
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Photograph of employee observed inside machine without equipment locked out
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Any exposed belts or chain drives?
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Describe observation
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Photograph of exposed belts or chain drives