Motor Termination Checklist Form
Complete this checklist to document the safe and thorough termination or removal of a motor from service.
Motor/Equipment Identification Number
*
Equipment Description
*
Location of Motor/Equipment
*
Reason for Termination/Removal
*
Please Select
Scheduled Maintenance
Equipment Failure
Upgrade/Replacement
Decommissioning
Other
Date and Time of Termination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Current Condition Status of Motor
*
Please Select
Operational
Non-Operational
Damaged
Unknown
Electrical Isolation/Disconnection Steps Completed
*
Yes
No
Not Applicable
Mechanical Removal Status
*
Fully Removed
Partially Removed
Not Removed
Parts/Components Removed or Retained
Coupling
Mounting Base
Shaft
Bearings
Electrical Connections
Other
Inspection Findings/Notes
Hazards Identified / Lockout-Tagout Notes
Responsible Technician/Department
*
Required Follow-Up Actions
Completion Approval
*
Approved
Not Approved
Submit Checklist
Should be Empty: