Machine Shutdown Checklist Form
Use this form to record a planned machine shutdown, confirm safety isolation steps, document issues, and track approval before restart.
Machine Details
Machine Name / ID
*
Department or Area
*
Exact Location
*
Shutdown Planning
Planned Shutdown Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shutdown Time
*
Hour Minutes
AM
PM
AM/PM Option
Reason for Shutdown
*
Please Select
Planned maintenance
Emergency shutdown
Inspection
Breakdown
Other
Shutdown Type
*
Planned maintenance
Emergency shutdown
Inspection
Breakdown
Other
Expected Duration
*
Responsible Personnel
Prepared by
*
First Name
Last Name
Job title / role
*
Contact information
*
Pre-Shutdown Status
Current Operating Status
*
Running
Idle
Paused
Maintenance Mode
Other
Last Run Time / Last Operational State
Active Alarms or Abnormal Conditions Observed
Isolation and Safety Steps
Power disconnected
*
Yes
Equipment isolated
*
Yes
Lockout/tagout applied
*
Yes
Hazardous energy sources secured
*
Yes
Pressure released
*
Yes
Moving parts stopped
*
Yes
Stored energy discharged
*
Yes
Utilities disconnected as applicable
Yes
Process and Material Condition
What remains in the machine?
*
Materials
Chemicals
Product
Pressure
Other
Details of remaining contents
Cleanup or containment completed
Drained remaining contents
Purged lines or vessel
Contained spills or leaks
Secured hazardous materials
Isolated residue for disposal
Other
Inspection and Issues Found
Inspection results
*
Complete
Incomplete
Not applicable
Other
Issues found during shutdown
Any damage, leaks, unusual noise, or unsafe conditions detected?
*
Yes
No
Corrective Actions and Follow-Up
Corrective actions required
*
Person responsible for follow-up
*
First Name
Middle Name
Last Name
Target completion date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Maintenance work order or internal ticket created?
*
Yes
No
Reference number (if applicable)
Review and Restart Control
Supervisor Review / Approval Name
*
First Name
Middle Name
Last Name
Review Status
*
Please Select
Approved
Needs Changes
Rejected
Restart Authorization Status
*
Authorized to Restart
Not Yet Authorized
Conditional Authorization
Restart Conditions or Restrictions Before Returning to Service
Submit
Should be Empty: