TPM Preventive Maintenance Checks and Services Worksh

For use of this form see the applicable TPM Standards for the piece of equipment being inspected. Date: Equipment Nomenclature: Location: Column a: Enter TPM Standards item # Column b: Enter the applicable condition status symbol Column c: Enter the deficiencies and shortcomings with specific details and location Time: Model: TPM Cleaning and Inspection Standard Date:

FORM COMPLETION INSTRUCTIONS

Column e: Individual affirming completed corrective

Column d: Show corrective action for deficiency or sh

Column f: Date the completed corrective action was p

NOTE 1: In Column "b" place the date that you are conducting the inspection and in column "c" print your name. on next line record any deficiencies, shortcomings, or corrective actions.

NOTE 2: After completion of inspection, if you are a student provide form to supervisor for review. Supervisor w sign his name and date verifying inspection (i.e., "Verfied by Brian Chase, Brian C. Chase, 04/15/2011"). Form wi maintained in Maintenance Binder in the room. Work Order, TPM Tag, Red Tag, or other documentation should b SOP, if applicable. Any safety hazards should be brought to the attention of supervisor immediately.

STATUS SYMBOLS
"X": Indicates a deficiency in the equipment that places it in an inoperable status. Safety hazards will also be indicated.

Horizontal Dash "--": Indicates that a required inspection replacement, maintenance operation check is due but has n accomplished.

Circled "X": Indicates a deficiency, however, the equipment may Diagonal "/": Indicates a material defect, other than a defi be operated under specific limitations as directed by higher must be corrected to increase efficiency or to make the item authority or as prescribed locally, until corrective action can be serviceable. accomplished. TPM # (a) Status (b)

Deficiencies and Shortcomings (c)

Corrective Action (d)

TPM # (a)

Status (b)

Deficiencies and Shortcomings (c)

Corrective Action (d)

ervices Worksheet
Type of Inspection: Serial #:

pment being inspected.

on Standard Date:

e action for deficiency or shortcoming in ( c )

ming completed corrective action was taken

ted corrective action was performed

lumn "c" print your name. Then starting

r for review. Supervisor will print and se, 04/15/2011"). Form will then be er documentation should be prepared IAW r immediately.

tes that a required inspection, component eration check is due but has not been

terial defect, other than a deficiency which efficiency or to make the item completely

Initial When Corrected (e)

Date (f)

Initial When Corrected (e)

Date (f)

TPM Preventive Maintenance Checks and Services Workshe

Date: Machine and Model: Date: Type of Inspection: Serial #: Operator Signature: Reference and Date: Location: Supervisor Signature: Frequency TPM # Status Deficiencies and Shortcomings Corrective Action Shift Day Week 2 Week Month

rksheet

e:

Time

Operator