Tech data/site survey form (lifts) Page 1 of 8

Rev 1.0 Jul 15

Technical Data/Site Survey Form (Lifts)

Site Address

Lift Reference

Engineer

Date

Lift Data:

1 Original manufacturer

2 Number of lifts in group

3 Type

4 Application

Other (Please Describe)

5 No. of stops

6 No. of openings

7 No. of car entrances

Multiple entrances

8 Lift installation Original Installation Major Reconstruction Part Refurbished

Date: Date: Date:

9 Serial number in car

10 CE mark present in car?

Notified body no:

11 Capacity Persons: KG: Load plate in car?

12 Contract speed

13 Machine room location

Other:

Tech data/site survey form (lifts) Page 2 of 8

Rev 1.0 Jul 15

Machine Room/Space – General

14 Door can be opened from the inside?

15 Ventilation/AC?

16 Fire extinguisher?

Suitable for electric?

17 Lighting operating ok?

18 Emergency lighting?

Tested Ok?

19 Light switch location

20 Electric shock Notice?

21 Release instructions?

22 Group lifts labeled?

23 Access clear/safe?

24 Space clear of other trades/materials?

25 Autodialler fitted?

Is it working?

Manufacturer/model

Line number

Programmed number 1

Programmed number 2

Programmed number 3

Programmed number 4

26 Main isolator lockable?

Labeled appropriately?

Fused?

Fuse rating and type

Neutral present?

27 Observations/recommendations:

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Tech data/site survey form (lifts) Page 3 of 8

Rev 1.0 Jul 15

Machine Room – Control Panel

28 Control panel

Make/model

Year of manufacture

29 Drive

Drive manufacturer

Drive model/serial no.

30 Ratings if available

31 Feedback

32 Incoming power supply

Measured voltage: Line to line volts:

33 Advance door opening

34 Direct to floor approach

35 Observations/recommendations:

Tech data/site survey form (lifts) Page 4 of 8

Rev 1.0 Jul 15

Machine Room – Machinery and Governor

36 Machine type

37 Manufacturer

38 Year of manufacture

39 Motor Data V: In: kW: RPM:

Serial No/type no.

40 Valve/Brake Voltage

41 Brake release tool

42 Brake switches present?

43 Screened motor cable?

44 Tacho/encoder/resolver manufacturer

Part number

Operating voltage

PPR (if applicable)

45 Uncontrolled movement Device?

Type

46 Guarding sufficient?

47 Moving parts yellow?

48 Overspeed governor

Serial number

Adjustment sealed?

49 Observations/recommendations:

Tech data/site survey form (lifts) Page 5 of 8

Rev 1.0 Jul 15

Lift Car

50 Stopping accuracy (mm)

51 Lighting Tubes (size: ) Down-lighters Both

Are they LED?

Emergency fitted?

Emergency working?

52 COP

Type

How many COP’s fitted?

53 Car Indicator

Location

No. of car indicators

54 Voice Annunciator

Announces floors?

Announces doors?

Announces direction?

55 Doors

Car doors

Other:

Landing doors

No. of door panels Car: Landing:

Reversal device

Operating ok?

56 Observations/recommendations including car lining condition:

Tech data/site survey form (lifts) Page 6 of 8

Rev 1.0 Jul 15

Car top/shaft

57 Door operator type: AC DC

Make/model

58 Car top control

59 Car top barrier fitted?

60 Suspension Other:

Ratio Other:

Size (mm):

Run-by measurement (mm):

Marked on C/W screen?

61 Shaft Encoder

62 Car top emergency light

Is it operable?

63 Car guide shoe type

Guide size (mm)

64 C/W guide shoe type

Guide size (mm)

65 Shaft lighting

How many fittings? No of emergency fittings:

Emergencies working?

Switching Machine room Pit Car top

Neon’s on switches?

Neon should be switched Neon should be lit Neon should be lit

66 Observations/recommendations:

Tech data/site survey form (lifts) Page 7 of 8

Rev 1.0 Jul 15

67 Free fall prevention

68 Safety rope

Size of safety rope (mm):

69 Governor return wheel debris guard?

70 Lift C/Weight yellow?

71 Buffer type

72 Compensation?

73 Landing indicators Lanterns Dot-matrix TFT Not fitted

Floors fitted to

74 Safety assessment, (include health & safety improvements, safe access, guarding, lighting, signage, stop switches, suspected asbestos, safe release systems etc…):

Tech data/site survey form (lifts) Page 8 of 8

Rev 1.0 Jul 15

Supplementary Testing If you feel that supplementary testing is in order to reinforce the safety/performance of a particular area of the lift equipment, please indicate by ticking the right hand column below Please indicate the tests recommended by ticking in the request test column below.

Request test

SAFed Test Ref Test Description

A1 Earth Continuity

A2 Electrical Safety Devices

A3 Terminal Speed Reduction Systems

A4 Landing Door Interlocks

A5 & A6 Geared Machines, Shafts and Plain Bearings, Roller, Ball and Needle Bearings, Sheaves

A7 Overspeed Governors (Calibration, Actuation)

A8, A9 & A10 Safety gear operation

A11 Over-speeding of ascending car

A12 Energy Dissipation Buffers Slow Speed

A13 Suspension systems

A14 Car Overload Detection Devices

A15 Hydraulic Systems

A16 Hydraulic Cylinders in bore holes

A17 Hydraulic Rupture/Restrictor Valves

A18 Electrical Anti-creep System

A19 Mechanical Anti-creep Device

A20 Low Pressure Detection Devices

A21 Traction, Brake and Levelling, Brake Condition, Brake Dynamic, Levelling

A22 Car/Counterweight Balance

GrounGrounds or evidence for calling for above requested tests: