An Example Risk-based Questionnaire

Below is an example of a risk-based questionnaire system. Several more will be offered in later chapters and the appendices. 

As you can see, these examples and others can be completed in hardcopy or electronic format. Many companies have electronic database systems for tracking the PSSR activities and the action items. 

Note that the short form is essentially the first page of the long form, which is further customized based upon the activity. For PSM and RMP covered facilities similar words should appear on any PSSR documentation performed for a covered process in order to confirm the process is ready for startup. 

GUIDELINES FOR PERFORMING EFFECTIVE PRE-STARTUP SAFETY REVIEWS 

TABLE 4-2 Example short form for lower risk / simple PSSR 

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