Safety Assessment Report (SAR) Audit Assessment Report For _____________________________________________________________________ Address: State: Zip: Facility Phone Number: ( ) Facility Fax#: ( ) Submitter: Email: Program Manager: Email: Audit Performed by: Date (dd/mm/year): DATA ITEM DESCRIPTION (DID) FACTORS DI-SAFT-80102B 950731) T.R.# Introduction section Answer Notes Does the SAR state in a narrative form the 1.1 purpose of the SAR? Yes No N/A (para 10.2.1) T.R.# System description section Answer Notes Is there a section which provides a description of the system? References to 2.1 technical manuals, system safety program Yes No N/A plan, system specifications can be used. (para10.2.2) Does the system description section include 2.2 the purpose of the system? Yes No N/A (para10.2.2(a)) Does the system description section include a 2.3 brief historical summary of the system’s Yes No N/A development? (para 10.2.2(b)) Does the system description section include a 2.4 brief description of the system and its Yes No N/A components? (para 10.2.2(c)) Does the system description section include 2.5 Yes No N/A the name of the system? (para 10.2.2(c)) Does the system description section 2.6 name/identify the type of system? Yes No N/A (para 10.2.2(c)) Does the system description section name/identify the model number of system? Yes No N/A 2.7 (para 10.2.2(c))
Safety Assessment Report (SAR) Audit Assessment Report For _____________________________________________________________________ Address: State: Zip: Facility Phone Number: ( ) Facility Fax#: ( ) Submitter: Email: Program Manager: Email: Audit Performed by: Date (dd/mm/year): DATA ITEM DESCRIPTION (DID) FACTORS DI-SAFT-80102B 950731) T.R.# Introduction section Answer Notes 1.1 Does the SAR state in a narrative form the purpose of the SAR? (para 10.2.1) Yes No N/A T.R.# System description section Answer Notes 2.1 Is there a section which provides a description of the system? References to technical manuals, system safety program plan, system specifications can be used. (para10.2.2) Yes No N/A 2.2 Does the system description section include the purpose of the system? (para10.2.2(a)) Yes No N/A 2.3 Does the system description section include a brief historical summary of the system’s development? (para 10.2.2(b)) Yes No N/A 2.4 Does the system description section include a brief description of the system and its components? (para 10.2.2(c)) Yes No N/A 2.5 Does the system description section include the name of the system? (para 10.2.2(c)) Yes No N/A 2.6 Does the system description section name/identify the type of system? (para 10.2.2(c)) Yes No N/A 2.7 Does the system description section name/identify the model number of system? (para 10.2.2(c)) Yes No N/A
Trumble_SAR_Audit_Tool.docx