SAFETY ACTION REPORT

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

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RECOMMENDED CORRECTIVE ACTION ____________________________________________________________

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ACTION TAKEN TO ELIMINATE HAZARD

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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: _______________________

Fork Lift Operator Check List

PROPANE POWERED LIFT TRUCKS OPERATOR CHECK LIST PAGE 1 OF 1

DATE: ____________ TRUCK #: __________ HOUR METER: _____________ DEPT. ____________

OPERATORS
				INDICATE OK OR NEEDS ATTN.
	PRE - OPERATIONAL CHECKS			O.K.	NEED ATTENTION
1	INSPECT FORKS (Cracks, Damage, Level, Locking Pins)
2	CARRIAGE (Bent or Damaged)
3	LIFT CHAINS (Tension, Mounting Pins Damaged)
4	LIFT CYL., TILT CYL., HYD. HOSES (Leaking or Damaged)
5	HOSE REEL (Damage, Leaks)
6	TIRES (Chunked, Separated, Damaged)
7	FLUIDS (Oil, Trans. Hydraulic)
8	RADIATOR (Level and for Leaks)
9	PROPANE TANK (Secure, S.V. Vertical, Leaks, & Gauge)
10	GENERAL CONDITION (Damage Etc.)
11	FIRE EXTINGUISHER
	OPERATIONAL CHECKS
1	EMERGENCY BRAKE (Forward, Reverse)
2	SERVICE BRAKE (Forward, Reverse)
3	STEERING (Left, Right)
4	HORN, LIGHTS (Operational, Damage)
5	BATTERY FLUID LEVEL
6	TIRES
7	NOISES
COMMENTS: (PLEASE EXPLAIN ALL ITEMS NEEDING ATTENTION)

TURN OVER IF ADDITIONAL SPACE IS REQUIRED FOR COMMENTS.

Spill Response Procedures

Major Spill

In the event of a spill which:

It involves the release of a type or quantity of a chemical that poses an immediate risk to health or it involves an uncontrolled fire or explosion:

Evacuate the building:

Call 911 and give details of the accident including location, types of hazardous materials involved, and whether there is personal injury. If the accident involves personal injury or chemical contamination, follow these steps:

1) Move the victim from the immediate area of fire, explosion, or spill (if this can be done without further injury to the victim or you).

2) Locate nearest emergency eyewash in shop. Remove any contaminated clothing from the victim and flush all areas of the body contacted by chemicals with copious amounts of water for 15 minutes.

3) Administer first aid as appropriate and seek medical attention.

Minor Spill

In the event of a spill involving the release of a type or quantity of a chemical which does not pose an immediate risk to health and does not involve chemical contamination to the body:

1. Notify personnel and neighbors of the accident.

2. Isolate the area. Close doors and evacuate the immediate area if necessary.

3. Remove ignition sources and unplug nearby electrical equipment.

4. Establish exhaust ventilation. Vent vapors to outside of building only (open windows).

5. Locate spill kit.

6. Choose appropriate personal protective equipment (goggles, face shield, impervious gloves, lab coat, apron, etc.)

7. Confine and contain spill. Cover with appropriate absorbent material. Acid and base spills should be neutralized prior to cleanup. Sweep solid material into a plastic dust pan and place in a sealed 5 gallon container.

8. Wet mop spill area. Be sure to decontaminate broom, dustpan, etc. Put all contaminated items (gloves, clothing, etc.) into a sealed 5 gallon container or plastic bag. Bring all waste to the next Waste Open House.

SPECIAL EMERGENCY TREATMENT

Skin Contact

1. Immediately flush with copious amounts of water under an emergency shower.

2. Remove all clothing while under the shower. Flush skin for 5 minutes.

3. Flush skin until medical personnel arrive.

4. Get medical attention immediately.

Eye Contact

1. Immediately flush eyes with water with the eyewash for 15 minutes.

2. Get medical attention immediately.