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Pre-Startup Safety Review Verification Form

Use this checklist to complete prior tasks before using the equipment. The checklist will help you prevent hazards that are usually unidentified because of the lack of pre-start inspections.
MaintainX
07/15/2022

Pre-Startup Safety Review Verification Form

Use this checklist to complete prior tasks before using the equipment. The checklist will help you prevent hazards that are usually unidentified because of the lack of pre-start inspections.

    Facility Information:

  • Name:

  • Address:

  • If new facility, assign PSSR #:

  • Scope of Work:

  • Verification Sign-Off:

  • Name / Title

  • Signature:

    Click here to sign
  • Date

  • Requirement

  • All process safety information has been compiled and is complete, current, and accurate. The information is accessible to the employees.

    • Yes
    • No
    • N / A
  • The process hazard analysis is complete for all new facilities, and the management of change has been completed for all modified facilities. The specific requirements of these elements have been completed satisfactorily.

    • Yes
    • No
    • N / A
  • All safety procedures have been developed, or modified, and are implemented.

    • Yes
    • No
    • N / A
  • All chemical handling procedures have been developed, or modified, and are implemented.

    • Yes
    • No
    • N / A
  • All maintenance procedures have been developed, or modified, and are implemented.

    • Yes
    • No
    • N / A
  • All emergency action procedures have been developed, or modified, and are implemented.

    • Yes
    • No
    • N / A
  • Construction and equipment is in accordance with the design specifications.

    • Yes
    • No
    • N / A
  • Training has been completed for all employees involved in handling hazardous chemicals

    • Yes
    • No
    • N / A
  • Training has been completed for all employees that are required to respond to emergencies involved in the process.

    • Yes
    • No
    • N / A
  • Approval to Startup Process:

  • Signature indicates that all pre-startup safety review items are completed. The approval for startup must be on or before the new or modified system was placed in service.

  • Name:

  • Title:

  • Signature:

    Click here to sign
  • Date:

  • Follow-up Items:

  • List any follow-up items which were not completed prior to system startup, the reason that the item has not been completed (in the Comment column) and fill in due date and the date that they are completed. The individuals who are authorized to approve the startup should ensure that the modified system is safe to startup even though these items have not been completed, i.e. the follow-up items should have no impact on system safety.

  • Follow-Up Items

    • Comment

    • Due Date

    • Date Completed

    Source: MaintainX (Community Member)

    Please note that any procedure, checklist, or other document available in the MaintainX Global Procedure Library is provided for general education and information only and does not constitute legal, medical, or financial advice. MaintainX makes the materials available AS IS and AS PROVIDED, without warranties of any kind. By downloading or using any such materials, you assume the risk that they may not be appropriate for your specific situation and agree that you are solely responsible for any such use, including compliance with applicable law and with meeting any conditions of product warranties.