Machine Details

Ice Machine Information

Machine Location

Serial Number

Due Date Sticker

If Yes, Date on Sticker:

Black or Pink/Orange Mold present?

If yes, location of mold:

Is tray under ice spout clean?

If no, explain:

Does the water spout appear clean?

If no, explain:

Is calcification, color coating present on spout?

If yes, explain:

Machine Utilization

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Condition

Container Type

Specify "Other" Type:

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Usage Observation
Person Using Machine

Specify "Other" Role:

Container Type

Specify "Other" Type:

Container Condition

Dumping Contents into Ice Machine Drain

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.