General • Inspections

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:

New Facility:

If new facility, assign PSSR #:

Modified Facility:

If modified facility, reference MOC #:

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.

Pre-Startup Safety Review Verification Form

Pre-Startup Safety Review Verification Form

Facility Information:

Name:

Address:

New Facility:

If new facility, assign PSSR #:

Modified Facility:

If modified facility, reference MOC #:

Scope of Work:

Verification Sign-Off:

Name / Title

Signature:

Date

Requirement

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

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.

All safety procedures have been developed, or modified, and are implemented.

All chemical handling procedures have been developed, or modified, and are implemented.

All maintenance procedures have been developed, or modified, and are implemented.

All emergency action procedures have been developed, or modified, and are implemented.

Construction and equipment is in accordance with the design specifications.

Training has been completed for all employees involved in handling hazardous chemicals

Training has been completed for all employees that are required to respond to emergencies involved in the process.

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:

Date:

Follow-up Items:

Follow-Up Items

Comment

Due Date

Date Completed