AECC Safety Advantage Form revision 1

• Date Catch Occured

  Date

• Name of Observer/Corrector:

• Site/Plant/Station
  Address

• Specific Location:

• Scope of Work:

Potential Unsafe Act

• Off

  On

• Affected?

  Select Employee Subcontractor Other

  • Employee
  • Subcontractor
  • Other

• Potential Consequence?

  Select Injury Illness Equipment Damage Property Damage Environmental Release Other

  • Injury
  • Illness
  • Equipment Damage
  • Property Damage
  • Environmental Release
  • Other

• Description

• Photos

  Media

• Action(s) Taken and Who Assigned:

• Significance Level Assigned by Management (1-5)

• Level Assigned:

Potential Unsafe Condition

• Off

  On

• Affected?

  Select Employee Subcontractor Other

  • Employee
  • Subcontractor
  • Other

• Potential Consequence?

  Select Injury Illness Equipment Damage Property Damage Environmental Release Other

  • Injury
  • Illness
  • Equipment Damage
  • Property Damage
  • Environmental Release
  • Other

• Description

• Photos

  Media

• Action Taken and Who Assigned:

• Significance Level Assigned by Management (1-5)

• Level Assigned?

Outstanding Safe Work Behavior

• Off

  On

• Affected?

  Select Employee Subcontractor Other

  • Employee
  • Subcontractor
  • Other

• Description

• Photos

  Media

• Significance Level Assigned by Management (1-5)

• Level Assigned?

Return this card to your supervisor. THANK YOU for your report