Mining Form

Free Fillable Equipment Safety Check

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MI-0738 fieldscompliance

Project Information

Mine / Project Name*

MSHA Mine ID*

Inspector / Examiner Name*

Inspection Date*

Inspection Time*

Shift

Equipment ID & Type

Equipment ID / Unit Number*

Equipment Type*

Make / Model

Serial Number

Hour Meter Reading

Assigned Operator Name

Safety Device Checks

Headlights / Working Lights*

Brakes / Parking Brake*

Horn / Audible Warning Devices*

Fire Suppression System*

Methane Monitor (if required)*

Machine Guarding / Covers Intact*

Hydraulic System (hoses, cylinders, fluid level)*

Trailing Cable / Power Supply Condition*

Ground Fault / Leakage Protection*

ROPS / FOPS (if applicable)

Seatbelt / Operator Restraint

Self-Rescuer Stored on Equipment (if required)

Deficiency Documentation

Deficiencies Found During InspectionDeficiencies Found During Inspection

Lockout / Tagout Status

Lockout / Tagout Required for Maintenance / InspectionLockout / Tagout Required for Maintenance / Inspection

Overall Result

Overall Inspection Result*

Inspector Notes

Inspector Confirms Report is Accurate and Complete*Inspector Confirms Report is Accurate and Complete

Photos

Location

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Related Compliance Forms

MSHA Inspection Report

MI-05

Ground Control Inspection

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Reclamation Inspection

MI-08