Information

  • Document No.

  • Conducted on

  • Location
  • Prepared by

  • Given to

  • 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

  • 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

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