Information
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Client Name:
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Client Address:
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Client Contact Name & Position:
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Conducted on
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Prepared by:
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What occurred in this area that you are following up on?
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Please list the area you are reassessing: (EG Front of warehouse - Isle number - Yard etc)
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Is the area that Accident, Incident or Near Miss occurred reopen and operating in a safe manor? (Picture if possible)
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Add media
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Have new procedures been put in place by the client to eliminate or lower the chance of reoccurrence? (If yes please list)
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Are you satisfied that these changes will help to eliminate or lower the chance of reoccurrence?
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Has consultation & training with the workers occurred on the new procedures? (Please list below : If YES how & when / If NO when will this occur)
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If first aid was used has the first aid kit been restocked?
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Client Signature
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Zoom Representative Signature
