THIS FORM MAY BE USED TO
REPORT SAFETY HAZARDS AND THE DETAILS OF CORRECTIVE ACTION WHICH HAS
BEEN TAKEN. BOTH HAZARDOUS CONDITIONS AND UNSAFE ACTS MAY BE
REPORTED ON THIS FORM.
PLEASE GIVE THE COMPLETED
FORM TO THE PERSON TO WHOM YOU USUALLY REPORT, AND SEND A COPY TO THE
HEALTH AND SAFETY REP.
TIME__________DATE__________
ADDRESS
_______________________________ CONSTRUCTOR
________________________________________
SITE SUPERVISOR
____________________________ DF SITE SUPERVISOR
______________________________
LOCATION OF THE HAZARD?
_____________________________________________________________________
DESCRIPTION OF THE HAZARDOUS
CONDITION OR ACT
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RECOMMENDED CORRECTIVE ACTION
____________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
ACTION TAKEN TO ELIMINATE
HAZARD
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
THE ‘ACTION TAKEN’ PORTION
OF THIS FORM MUST BE COMPLETED WITHIN 21 CALENDAR DAYS. PLEASE SEND A
COPY TO THE HEALTH AND SAFETY REP SO THAT THE LOG CAN BE UPDATED.
REPORTED BY
_______________________
REPORTED TO
_______________________
Reviewed by manager
of operations Action against
Date:
____________________ Date: ______________________
Signature:
___________________ Signature: _______________________
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