Machine Maintenance Permit

Machine Maintenance Permit
This Machine Maintenance Permit is required anytime a protective guard is removed or by-passed.
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Machine Name
Maintenance being performed?
Be specific and note any energy isolation requirements needed
Does this maintenance order require Energy Isolation?

YesNo
Does this maintenance require removal of a guard?

YesNo
You must complete the Machine Guarding training before performing Machine Maintenance that requires guard removal.
Have you completed the Machine Guarding training?

YesNo
Post-Maintenance Responsibilities
Have all tools been removed from the machine?

YesNo
Have the guards been put back in place?

YesNo
Should be Empty:

Post-Maintenance Responsibilities