Process Safety Management

Company: Division or Location:

Name: Date:
PSM Elements
Select which elements of the PSM standard you will work on:
☐ Process hazard analysis ☐ Pre-startup safety review (PSSR)
☐ Process safety information update ☐ Safe work practices update
☐ Operating procedure update ☐ Mechanical integrity information update
☐ Operator training ☐ Contractor training
☐ Employee notification ☐ Offsite impact
☐ Maintenance training ☐ Other:
Management of Change Activities
List out any of the changes you will make that fall under the management of change requirement.
Typically, this involves any changes to equipment, processes, or personnel that relate to the use of
highly hazardous chemicals.

Title Status
☐ Not Started ☐ In Process ☐ Complete
☐ Not Started ☐ In Process ☐ Complete
☐ Not Started ☐ In Process ☐ Complete
☐ Not Started ☐ In Process ☐ Complete
☐ Not Started ☐ In Process ☐ Complete
☐ Not Started ☐ In Process ☐ Complete
☐ Not Started ☐ In Process ☐ Complete
☐ Not Started ☐ In Process ☐ Complete
Control Documents
List out any of the control documents you will need to update (if applicable):

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