Machine Operator Safety Assessment Form
Use this form to assess a machine operator's safety readiness, equipment checks, training status, and corrective actions needed.
Operator Information
Operator Full Name
*
First Name
Last Name
Job Title / Role
*
Department / Team
*
Shift
*
Day
Swing
Night
Rotating
Other
Supervisor Name
*
Machine and Work Context
Machine or Equipment Operated
*
Machine Type or Category
*
Please Select
Forklift
Conveyor
Press
Lathe
CNC Machine
Crane
Excavator
Mixer
Packaging Machine
Other
Work Area or Location
*
Date of Assessment
*
-
Month
-
Day
Year
Date
Experience on This Machine (Years or Months)
*
Safety Training and Authorization
Have you completed the required machine safety training?
*
Yes
No
In progress
Are you currently authorized to operate this machine?
*
Yes
No
Pending review
Date of last safety training or refresher
*
-
Month
-
Day
Year
Date
Additional safety certifications relevant to this machine
Pre-Shift Safety Checks
Pre-shift inspection checklist
*
Rows
Pass
Needs attention
Not applicable
Guards in place
1
2
3
Emergency stop working
4
5
6
Controls functioning properly
7
8
9
Warning labels visible
10
11
12
Leaks or damage present
13
14
15
Housekeeping around the machine satisfactory
16
17
18
Lockout/tagout status verified when applicable
19
20
21
Inspection comments
Overall inspection status
*
Pass
Needs attention
Not applicable
Guards in place
*
Pass
Needs attention
Not applicable
Emergency stop working
*
Pass
Needs attention
Not applicable
Controls functioning properly
*
Pass
Needs attention
Not applicable
Warning labels visible
*
Pass
Needs attention
Not applicable
Leaks or damage present
*
Pass
Needs attention
Not applicable
Personal Protective Equipment and Safe Practices
PPE Required for This Task
*
Safety glasses
Hearing protection
Hard hat
Gloves
Steel-toe boots
High-visibility vest
Face shield
Respirator
Other
PPE Worn Correctly
*
Always
Usually
Sometimes
Rarely
Never
Adherence to Safe Operating Procedures
*
Not at all
1
2
3
4
5
6
7
8
9
Fully
10
1 is Not at all, 10 is Fully
Understanding of Lockout/Tagout Procedures
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Awareness of Pinch, Crush, and Caught-In Hazards
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Incident History and Hazard Reporting
Has the operator experienced any accidents, near-misses, injuries, or unsafe-condition reports related to machine operation?
*
Yes
No
If yes, provide details, dates, and actions taken
Hazards currently observed during this assessment
Assessment Results and Corrective Actions
Overall Safety Rating
*
1
2
3
4
5
Assessment Outcome
*
Satisfactory
Needs Improvement
Unsatisfactory
Identified Corrective Actions
Target Completion Date
-
Month
-
Day
Year
Date
Supervisor/Assessor Observations
Submit Assessment
Should be Empty: