• Document No.

  • Audit Title

  • Client / Site Name:

  • Site Address:
  • Conducted on

  • Requested by:

  • Prepared by

  • Personnel attending:

  • Facility description

  • General reason for visit:

  • Current Linac:

  • Photo of current linac

  • Current top energy:

  • Proposed replacement System:

  • General discussion:

  • Customer expectations:

  • Follow ups:

Vault Parameters

  • Vault door width and height:

  • ISO to back wall:

  • ISO to patient foot:

  • ISO to A-side:

  • ISO to B-side

  • Quick drawing of vault:

  • Photo of existing vault

  • Ceiling height:

  • Control room location:

  • Control room width:

  • Control room depth

  • Photo of control room

  • Control room drawing


  • Current chilled water supply:

  • City water backup?

  • Current electrical supply? Include location, ampacity, voltage.


  • General description of path. General length, hall width, door width & height.

  • General description of staging area:

  • Photo of staging area:

  • Standard delivery?

  • Does this delivery fall under standard delivery?

  • Dock or ground delivery?

  • Explain why rigging does not fall under standard rigging.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.