Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Incident Description
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National, Contractor, Sub-contractor, Employee?
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Was there any injury to person/s?
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Was there any damage to property?
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Has the zone / area foreman been informed about the incident?
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Can the work be safely completed after remedial action?
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Area / Zone description
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Short description of the incident.
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Photo of the area / incident
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Name and signature of person/s involved?
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Name and signature of person/s involved?
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Name and signature of person/s involved?
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Name and signature of person/s involved?
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Name and signature of person/s involved?
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Name and signature of person/s involved?
Actions taken by person leading the incident response?
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Stop work immediately?
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Make area concerned safe?
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Informed relevant managers / supervisors?
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Informed persons involved why incident response action has been taken?
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Performed a safety stand down with all persons involved and witnesses?
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Topic covered during the SWA stand down.
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Acquired all relevant information and details from person/s involved?
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Submit SWA immediately after stand down for record / filing purposes?
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Resources made available to mitigate risks in place?
Actions required for resolution of incident.
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List actions to be taken.
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Name and signature of person responsible for action.
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Date and time for action to be completed.
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Has work continued after SWA stand down?
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How was the situation resolved so work could resume safely?
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Potential consequences if work was not stopped?
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Time when work commenced
Recommendations
Zone / Area foreman or HSE officer acknowledgment
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