Pump Assessment Form
Use this form to evaluate the condition and performance of pumps during inspection. Complete all relevant fields for a thorough assessment.
Pump Identification Number
*
Location of Pump
*
Type of Pump
*
Please Select
Centrifugal
Submersible
Diaphragm
Gear
Other
Overall Visual Condition
*
Excellent
Good
Fair
Poor
Pump Performance Rating
*
1
2
3
4
5
Assessment of Key Pump Aspects
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Pump operates smoothly
1
2
3
4
5
No unusual noises or vibrations
6
7
8
9
10
No visible leaks
11
12
13
14
15
Controls function as expected
16
17
18
19
20
Pass/Fail Assessment
*
Pass
Fail
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Name
*
First Name
Last Name
Additional Comments
Submit Assessment
Should be Empty: