Title Page
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Conducted on
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Prepared by
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Equipment/Dept
General Requirements
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Guards prevent worker’s hands, arms, or other body parts from making contact with moving parts
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Action Taken:
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Guards firmly secured and not easily removable
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Action Taken:
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Guards permit safe, comfortable, and relatively easy operation of the machine
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Action Taken:
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Machine controls within easy reach of the operator
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Action Taken:
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Procedures established to ensure machine is shut down before guard is removed
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Action Taken:
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Emergency stop (button or pull cord) is readily accessible by machine operator and functionality has been verified
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Action Taken:
Guarding of Mechanical Hazards
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Point-of-operation guards provided and in place
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Action Taken:
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Gears, sprockets, pulleys, and flywheels guarded
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Action Taken:
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Belts, chain drives , and pump shafts guarded
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Action Taken:
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Exposed set screws, key ways, collars, and the like guarded
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Action Taken:
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Guards provided for any other hazardous moving part of the machine
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Action Taken:
Evaluation of Non-Mechanical Hazards
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Noise measurements acceptable
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Action Taken:
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Substances used in machine operations evaluated
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Action Taken:
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Electrical cords or connectors in good repair
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Action Taken:
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Personal protective equipment available, where necessary
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Action Taken:
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Operator dressed safely for the job per JHA and PPE hazard assessment
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Action Taken:
Training
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Workers trained in the recognition of machine hazards and the importance of using safeguards
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Action Taken:
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Lockout/tagout training provided, where necessary and instructions in place at equipment.
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Action Taken:
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Electrical Safety-Related Work practices training provided, where necessary
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Action Taken:
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Personal protective equipment training provided, where necessary
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Action Taken:
Other
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Equipment specific energy control procedure have been developed and are available for the equipment
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Action Taken:
