Functional Safety Verification Checklist
Use this checklist to verify functional safety coverage, test outcomes, hazards, and corrective actions for the system or process being reviewed.
Verification Overview
System / Item Being Verified
*
Project / Program Name
*
Verification Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Verification Stage / Milestone
*
Requirements Review
Design Review
Implementation Review
Test Execution
Pre-Release Review
Other
Completed By (Name / Role)
*
Safety Requirement Coverage
Requirements baseline / specification reference
*
Safety requirements coverage table
*
Hazard and Risk Review
Identified Hazards or Unsafe Conditions
*
Severity Level
*
Negligible
1
2
3
4
Critical
5
1 is Negligible, 5 is Critical
Likelihood / Occurrence Level
*
Rare
1
2
3
4
Frequent
5
1 is Rare, 5 is Frequent
Existing Control Measures
Residual Risk Assessment
*
Acceptable
Acceptable with Actions
Not Acceptable
Functional Safety Test Results
Were all required safety functions tested?
*
Yes
No
Partially
Not Applicable
Test environment or conditions
Test date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Observed results
*
Failed or incomplete test items
Findings and Corrective Actions
Nonconformities or Issues Found
*
Corrective Action Required
*
Owner / Responsible Person or Team
*
Target Completion Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Priority Level
*
Low
Medium
High
Critical
Current Action Status
*
Please Select
Open
In Progress
Blocked
Closed
Final Verification Decision
Overall Verification Outcome
*
Pass
Pass with Conditions
Fail
Readiness for Release or Deployment
*
Ready for Release
Ready with Follow-up Actions
Not Ready for Release
Reviewer Comments or Final Notes
Final Confirmation
*
I confirm this final verification decision
I do not confirm this final verification decision
Submit Checklist
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