Information
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Document No.
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Conducted on
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Location
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Prepared by
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Given to
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Condition or Practice
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Part/Section of Title 30 CFR:
Inspector's Evaluation
Gravity: Injury or illness (has) (is): (check one)
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No Likelihood
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Unlikely
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No Likelihood
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Reasonably Likely
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Highly Likely
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Occurred
Severity: Injury/Illness could reasonably be expected to be: (check one)
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No Lost Workdays
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Lost Workdays/Restricted Duty
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Permanently Disabling
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Fatal
Significant and Substantial: (check one)
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Yes
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No
Persons Potentially Affected: (check one)
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0
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1
-
2
-
3
-
4
-
5
-
6
-
7
-
8
-
9
-
10
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11 or more
Negligence: (check one)
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No Negligence
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Low Negligence
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Moderate Negligence
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High Negligence
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Reckless Disregard
Action to Terminate
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Action to Terminate
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Termination Due Date
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Picture of Findings
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Inspectors Signature
Termination Completion
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Termination Signature
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Termination Date
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Condition or Practice
-
Part/Section of Title 30 CFR:
Inspector's Evaluation
Gravity: Injury or illness (has) (is): (check one)
-
No Likelihood
-
Unlikely
-
No Likelihood
-
Reasonably Likely
-
Highly Likely
-
Occurred
Severity: Injury/Illness could reasonably be expected to be: (check one)
-
No Lost Workdays
-
Lost Workdays/Restricted Duty
-
Permanently Disabling
-
Fatal
Significant and Substantial: (check one)
-
Yes
-
No
Persons Potentially Affected: (check one)
-
0
-
1
-
2
-
3
-
4
-
5
-
6
-
7
-
8
-
9
-
10
-
11 or more
Negligence: (check one)
-
No Negligence
-
Low Negligence
-
Moderate Negligence
-
High Negligence
-
Reckless Disregard
Action to Terminate
-
Action to Terminate
-
Termination Due Date
-
Picture of Findings
-
Inspectors Signature
Termination Completion
-
Termination Signature
-
Termination Date
-
Condition or Practice
-
Part/Section of Title 30 CFR:
Inspector's Evaluation
Gravity: Injury or illness (has) (is): (check one)
-
No Likelihood
-
Unlikely
-
No Likelihood
-
Reasonably Likely
-
Highly Likely
-
Occurred
Severity: Injury/Illness could reasonably be expected to be: (check one)
-
No Lost Workdays
-
Lost Workdays/Restricted Duty
-
Permanently Disabling
-
Fatal
Significant and Substantial: (check one)
-
Yes
-
No
Persons Potentially Affected: (check one)
-
0
-
1
-
2
-
3
-
4
-
5
-
6
-
7
-
8
-
9
-
10
-
11 or more
Negligence: (check one)
-
No Negligence
-
Low Negligence
-
Moderate Negligence
-
High Negligence
-
Reckless Disregard
Action to Terminate
-
Action to Terminate
-
Termination Due Date
-
Picture of Findings
-
Inspectors Signature
Termination Completion
-
Termination Signature
-
Termination Date
-
Condition or Practice
-
Part/Section of Title 30 CFR:
Inspector's Evaluation
Gravity: Injury or illness (has) (is): (check one)
-
No Likelihood
-
Unlikely
-
No Likelihood
-
Reasonably Likely
-
Highly Likely
-
Occurred
Severity: Injury/Illness could reasonably be expected to be: (check one)
-
No Lost Workdays
-
Lost Workdays/Restricted Duty
-
Permanently Disabling
-
Fatal
Significant and Substantial: (check one)
-
Yes
-
No
Persons Potentially Affected: (check one)
-
0
-
1
-
2
-
3
-
4
-
5
-
6
-
7
-
8
-
9
-
10
-
11 or more
Negligence: (check one)
-
No Negligence
-
Low Negligence
-
Moderate Negligence
-
High Negligence
-
Reckless Disregard
Action to Terminate
-
Action to Terminate
-
Termination Due Date
-
Picture of Findings
-
Inspectors Signature
Termination Completion
-
Termination Signature
-
Termination Date
-
Condition or Practice
-
Part/Section of Title 30 CFR:
Inspector's Evaluation
Gravity: Injury or illness (has) (is): (check one)
-
No Likelihood
-
Unlikely
-
No Likelihood
-
Reasonably Likely
-
Highly Likely
-
Occurred
Severity: Injury/Illness could reasonably be expected to be: (check one)
-
No Lost Workdays
-
Lost Workdays/Restricted Duty
-
Permanently Disabling
-
Fatal
Significant and Substantial: (check one)
-
Yes
-
No
Persons Potentially Affected: (check one)
-
0
-
1
-
2
-
3
-
4
-
5
-
6
-
7
-
8
-
9
-
10
-
11 or more
Negligence: (check one)
-
No Negligence
-
Low Negligence
-
Moderate Negligence
-
High Negligence
-
Reckless Disregard
Action to Terminate
-
Action to Terminate
-
Termination Due Date
-
Picture of Findings
-
Inspectors Signature
Termination Completion
-
Termination Signature
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Termination Date
