Machine Assessment Questionnaire
Please complete this form to assess the condition and performance of the machine. Your responses will help ensure safety, efficiency, and compliance.
Machine Information
Provide details about the machine being assessed.
Machine Name or Type
*
Machine Serial Number or ID
*
Location of Machine
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor's Full Name
*
First Name
Last Name
Rate the overall operational status of the machine.
*
1
2
3
4
5
Safety and Functionality Checklist
*
Rows
Satisfactory
Needs Attention
Not Applicable
Emergency stop functions correctly
1
2
3
Safety guards in place and undamaged
4
5
6
Warning labels are visible and legible
7
8
9
No abnormal noises or vibrations
10
11
12
All controls operate smoothly
13
14
15
Is the machine due for scheduled maintenance?
*
Yes
No
Not Sure
Are there any visible signs of wear or damage?
*
Yes
No
Please provide details if you answered 'Yes' to visible signs of wear or damage.
Compliance with operational procedures
*
Non-compliant
1
2
3
4
Fully compliant
5
1 is Non-compliant, 5 is Fully compliant
Additional Comments or Recommendations
Submit Assessment
Should be Empty: