Safety Chair Service Inspection (NEW)

• Customer Name

• Customer Address
  Address

• Date of Service

  Date

• Engineer Name

Type of Service

• Annual Service

• Repair/Replace only

• Reason

Chair inspection

• Chair type

• Manufacturer

• Equipment location and level

• Serial No.

• Year of manufacture

  Select

• Signage present

  Present

  Not Present

• Recommendations

• Condition of dust cover

  Good

  Fair

  Poor

  N/A

• Reason

• Wall hooks/Stand present and secure

  Yes

  No

  N/A

• Reason

  None fitted

  Requires attention

• Recommendations

• Recommendations

• Angle of stair and nosing checked

• Cleanliness and appearance of chair

  Good

  Fair

  Poor

  N/A

• Recommendations

• Chair opens/closes operation checked

  Pass

  Fail

  N/A

• Description

• Chair handles condition and locking mechanisms engage

  Pass

  Fail

  N/A

• Description

• Hammock and headrest textile condition, zips and stitching condition

  Good

  Fair

  Poor

  N/A

• Description

• All wheels operational, in good condition and braking mechanism checked

  Pass

  Fail

  N/A

• Description

• Rotation and condition of traction belts, rollers & track assembly

  Pass

  Fail

  N/A

• Description

• Passenger safety belts operational and secure (waist, headrest, legs and feet where applicable)

  Pass

  Fail

  N/A

• Description

• Nuts, bolts, rivets and cap ends secure and in place

  Pass

  Fail

  N/A

• Description

• Accessories - Cabinet, alarm, comfy seat etc checked

  Yes

  No

  N/A

• Accessories checked

• Additional Comments

  Yes

  No

• Comments

• SERVICE RESULT

  Pass

  Fail

  N/A

• Reason

• Engineer name

  Sign

• Customer name and signature

  Sign

• Date

  Date

• Staff training in date and certified

  Yes

  No

  Unknown

• Contact information given to customer

  Yes

  No

  N/A

• Contact information given to customer

  Yes

  No

  N/A