Vehicle Barrier Safety Assessment Form
This form is for inspecting the condition, operation, signage, and hazards of vehicle barriers, and for recording corrective actions and overall safety status.
Date of Assessment
*
-
Month
-
Day
Year
Date
Inspector Name
*
First Name
Last Name
Barrier Location
*
Barrier Physical Condition
*
1
2
3
4
5
Barrier Operational Status
*
Operational
Requires Maintenance
Non-Operational
Signage and Markings Visibility
*
1
2
3
4
5
Hazards Present Near Barrier
Obstructed Access
Trip Hazards
Sharp Edges
Electrical Risks
Other
Assessment Checklist
*
Rows
Pass
Fail
N/A
Barrier arm or gate intact
1
2
3
Warning lights functioning
4
5
6
Emergency release accessible
7
8
9
No visible damage to mechanism
10
11
12
Corrective Actions Required
Estimated Timeframe for Corrective Actions
Please Select
Immediate (within 24 hours)
Short Term (1-7 days)
Medium Term (1-4 weeks)
Long Term (over 1 month)
Overall Safety Status
*
Safe
Requires Attention
Unsafe
Submit Assessment
Should be Empty: