Worker Safety Maintenance Checklist Form
Complete this checklist to document workplace maintenance safety inspections. Ensure all sections are filled accurately before submission.
Work Area or Equipment Inspected
*
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Name
*
First Name
Last Name
Shift
*
Please Select
Morning
Afternoon
Night
Other
Maintenance Task Type
*
Please Select
Routine Maintenance
Preventive Maintenance
Corrective Maintenance
Emergency Repair
Other
Current Safety Status
*
Safe
Unsafe
Requires Attention
Hazards Found
Corrective Action Needed
Equipment/Tag-Out Status
*
Operational
Tag-Out Applied
Out of Service
Completion Confirmation
*
I confirm all maintenance checks are complete
Submit Checklist
Should be Empty: