Industrial Control Site Survey Form
Use this form to document an industrial control site survey, including site details, control system overview, equipment condition, power and network status, safety observations, and follow-up recommendations.
Site and Contact Details
Site Name
*
Site Address or Location Description
*
Primary Contact Name
*
Primary Contact Role/Title
Contact Phone or Work Email
*
Survey Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Survey Type / Purpose
*
Please Select
Initial Survey
Follow-Up
Expansion
Maintenance Review
Other
Control System Overview
Control system type
*
PLC
SCADA
DCS
RTU
HMI
Other
Manufacturer / vendor
Approximate installation year
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of control panels or cabinets observed
Operating status
*
Fully operational
Partially operational
Offline
Unknown
Equipment and Infrastructure Survey
Control panels/cabinets condition
*
Rows
Good
Needs Attention
Critical Issue
Not Present
Not Inspected
Control panels/cabinets condition
1
2
3
4
5
Wiring and cable management
*
Rows
Good
Needs Attention
Critical Issue
Not Present
Not Inspected
Wiring and cable management
6
7
8
9
10
Grounding and bonding
*
Rows
Good
Needs Attention
Critical Issue
Not Present
Not Inspected
Grounding and bonding
11
12
13
14
15
Labeling and identification
*
Rows
Good
Needs Attention
Critical Issue
Not Present
Not Inspected
Labeling and identification
16
17
18
19
20
Enclosure integrity
*
Rows
Good
Needs Attention
Critical Issue
Not Present
Not Inspected
Enclosure integrity
21
22
23
24
25
Network switches and communications gear
*
Rows
Good
Needs Attention
Critical Issue
Not Present
Not Inspected
Network switches and communications gear
26
27
28
29
30
Sensors and field devices
*
Rows
Good
Needs Attention
Critical Issue
Not Present
Not Inspected
Sensors and field devices
31
32
33
34
35
Spare capacity and space for expansion
*
Rows
Good
Needs Attention
Critical Issue
Not Present
Not Inspected
Spare capacity and space for expansion
36
37
38
39
40
Notes on observed issues
Power, Network, and Environmental Conditions
Primary power source
*
Utility mains
Generator
Solar
Battery backup
Other
UPS or backup power present?
*
Yes
No
Surge protection present?
Yes
No
Network connectivity status
*
Please Select
Stable wired
Stable wireless
Intermittent
No connectivity
Other
Remote access needed?
Yes
No
Temperature and ventilation concerns
*
No concern
1
2
3
4
5
6
7
8
9
Severe concern
10
1 is No concern, 10 is Severe concern
Dust, moisture, or vibration exposure
*
Low exposure
1
2
3
4
5
6
7
8
9
High exposure
10
1 is Low exposure, 10 is High exposure
Overall environmental risk notes
Safety, Access, and Compliance Observations
Access Restrictions
*
Restricted Area
Badge Access Only
Escort Required
Limited Hours Access
Permit Required
Other
Required Escort or PPE
*
Safety Glasses
Hard Hat
High-Visibility Vest
Safety Boots
Hearing Protection
Gloves
Respirator
Escort Required
Other
Lockout/Tagout or Isolation Considerations
Emergency Shutdown Visibility
Clearly Visible
Partially Visible
Not Visible
Not Confirmed
Fire Protection Observations
Adequate and Operational
Present, Needs Attention
Not Present
Not Confirmed
Immediate Hazards or Deficiencies Observed
Recommendations and Follow-Up
Priority Level for Corrective Action
*
Low
Medium
High
Urgent
Recommended Next Steps
*
Parts, Materials, or Services Likely Needed
Spare Parts
Replacement Components
Cabling
Software Update
Calibration Services
Electrical Work
Mechanical Repair
Vendor Support
Other
Target Follow-Up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Follow-Up Visit Required
*
Yes
No
Submit Survey
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