MONTHLY INSPECTION CHECKLIST

GOTCHA KIT

Inspection Date:
To be Checked
No Kit No. Type/ Brand Location Upper and Remarks
Attachment Rope Rescue Attachment
lower Gotcha Frog Rope Grabba Karabiners
pole controller Rope slings
pulleys
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note Inspected by: Acknowledged by:
ü : Good
û : Bad
NA : Not Applicable
 MONTHLY INSPECTION CHECKLIST
SPILL KIT

Inspection Date:
To be Checked
Chem. PPE
No Kit No. Type/ Brand Location Path Remarks
Absorbent Disposal bag Dustpan and Kit container Waste (gloves,
obstruction to signage
(roll, pad) and ties broom condition Container goggles, suit,
Kit
etc.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note Inspected by: Acknowledged by:
ü : Good
û : Bad
NA : Not Applicable
 MONTHLY INSPECTION CHECKLIST
EYE WASH

Inspection Date:
To be Checked
Eye Wash External Water
No Type/ Brand Location Covers Leak or Path signage Remarks
No. unit Nozzle and Water level flow to
(tank, damage to obstruction to and Others
condition tube and clean nozzle
nozzle) unit unit checklist
(clean) level
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note Inspected by: Acknowledged by:
ü : Good
û : Bad
NA : Not Applicable
 MONTHLY INSPECTION CHECKLIST
SCBA

Inspection Date:
To be Checked

No SCBA No Type/ Brand Location Cylinder/ ICM Mask and Remarks

Demand valve/ Connector Harness Pressure
Pressure alarm rubber Face piece Cleaned
Regualtor tubes components gauges
gauges system seal

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note Inspected by: Acknowledged by:
ü : Good
û : Bad
NA : Not Applicable
 MONTHLY INSPECTION CHECKLIST
FIRE EXTINGUISHER

Inspection Date:
To be Checked
No FE No Type Location Hose & Pressure Instruction Wheel& Remarks
Cylinder Pin&seal Handle Tag Others
connection gauge label trolley
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note Inspected by: Acknowledged by:
ü : Good
û : Bad
NA : Not Applicable
 MONTHLY INSPECTION CHECKLIST
SMOKE DETECTOR

Inspection Date:
To be Checked
No Type/Brand Location Line Smoke/ Instruction Alarm Remarks
Indicator Tag Others
Installation Heat Test Line Test
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note Inspected by: Acknowledged by:
: Good
: Bad
: Not Applicable
 MONTHLY INSPECTION CHECKLIST
EMERGENCY LAMP

Inspection Date:
To be Checked
Emergency Leak or
No Type/Brand Location Lamp Cable & Instruction Remarks
Lamp No Main Lamp Damage to Battery Tag Alarm Bell Others
Indicator Connection Label
Unit
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note Inspected by: Acknowledged by:
ü : Good
û : Bad
NA : Not Applicable