Robot Safety Inspection Survey
Complete this survey to assess the safety and compliance of robots in your facility.
Inspector Name
*
First Name
Last Name
Inspector Email Address
*
example@example.com
Date and Time of Inspection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Robot Identification Number
*
Robot Location (Area/Department)
*
Robot Type/Model
*
Safety Inspection Checklist
*
Rows
Pass
Fail
N/A
Emergency stop button functional
1
2
3
Safety barriers/guards in place
4
5
6
Warning signs and labels visible
7
8
9
Sensors and interlocks operational
10
11
12
No exposed wiring or moving parts
13
14
15
Routine maintenance up to date
16
17
18
Overall Compliance Rating
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Were any hazards identified during the inspection?
*
Yes
No
If hazards were identified, describe them and specify corrective actions taken or recommended.
Additional Comments or Observations
Submit Inspection
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