Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Safety Gate Interlocks / Guard Switches
Safety Switch
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Make / Manufacturer
- Pilz
- Guardmaster
- Banner
- Euchner
- Mechan
- Dold
- Sick
- Schleicher
- REER
- Carlo Gavazzi
- Omron/STi
- Bernstein
- Leuze
- Balluff
- Datasensor
- Selet
- Diell
- Kronenberg
- Schneider
- Telemechanique
- Rockwell
- Other
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Model Number
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Number of contacts connected?
- 1 n/c
- 1 n/o
- 2 n/c
- 2 n/o
- 3 n/c
- 3 n/o
- 1 n/o + 1 n/c
- 2 n/o + 2 n/c
- Other
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Specify contact arrangement connected?
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How many devices of this type on the machine?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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Are multiple devices connected in series?
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Is it functional, does it stop the machine?
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Is it mechanically damaged?
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Additional Notes
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Emergency Stops and Lanyard Switches
EStop or Lanyard Switch
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Device Picture
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Make / Manufacturer
- Pilz
- Guardmaster
- Banner
- Euchner
- Mechan
- Dold
- Sick
- Schleicher
- REER
- Carlo Gavazzi
- Omron/STi
- Bernstein
- Leuze
- Balluff
- Datasensor
- Selet
- Diell
- Kronenberg
- Schneider
- Telemechanique
- Rockwell
- Other
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Model Number
-
Number of contacts connected?
- 1 n/c
- 1 n/o
- 2 n/c
- 2 n/o
- 3 n/c
- 3 n/o
- 1 n/o + 1 n/c
- 2 n/o + 2 n/c
- Other
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Specify contact arrangement connected?
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How many devices of this type on the machine?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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Are multiple devices connected in series?
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Is it functional, does it stop the machine?
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Is it mechanically damaged?
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Additional Notes
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ESPE's, Light Curtains, Light Grids and Laser Scanners
Optical Safety Device
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Photo of Device
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Type of Devices in place
- Type 2 Light Curtain <40mm Res, Hand/Finger
- Type 4 Light Curtain <40mm Res, Hand/Finger
- Type 2 Light Fence >40mm Res, Body Access
- Type 4 Light Fence >40mm Res, Body Access
- Laser Scanner
- Single Beam Optical Safety Sensos
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Make / Manufacturer
- Pilz
- Guardmaster
- Banner
- Euchner
- Mechan
- Dold
- Sick
- Schleicher
- REER
- Carlo Gavazzi
- Omron/STi
- Bernstein
- Leuze
- Balluff
- Datasensor
- Selet
- Diell
- Kronenberg
- Schneider
- Telemechanique
- Rockwell
- Other
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Model Number
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Is it functional, does it stop the machine?
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Is it mechanically damaged?
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Does the System use muting?
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Type of Muting?
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Describe Arrangement
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Additional Notes
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2 Handed Controls, Enabling Switches, Jog and Hold-to-Run
Complimentary Safety Device
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Picture of Device
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Make or Manufacturer
- Pilz
- Guardmaster
- Banner
- Euchner
- Mechan
- Dold
- Sick
- Schleicher
- REER
- Carlo Gavazzi
- Omron/STi
- Bernstein
- Leuze
- Balluff
- Datasensor
- Selet
- Diell
- Kronenberg
- Schneider
- Telemechanique
- Rockwell
- Other
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