SCBA Safety Assessment Survey
Complete this survey to assess the safety and readiness of Self-Contained Breathing Apparatus (SCBA) equipment.
Name of Assessor
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Role/Position
*
Please Select
Firefighter
Safety Officer
Maintenance Technician
Supervisor
Other
SCBA Equipment Serial Number or Asset Tag
*
SCBA Equipment Inspection Checklist
*
Rows
Pass
Fail
N/A
Cylinder pressure within safe range
1
2
3
Harness and straps in good condition
4
5
6
Facepiece clean and intact
7
8
9
Hoses and connections secure
10
11
12
Alarm and warning devices functional
13
14
15
Operational Readiness Status
*
Ready for Use
Requires Maintenance
Remove from Service
Additional Comments or Observations
Submit Assessment
Should be Empty: