Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

Report Form

Asset Area

  • Wastewater

  • Dams

  • Groundwater

  • Trunk Mains

  • Discipline

Asset Details

  • Location / Site

  • Equipment

  • Functional Location Number

Deficiency Details

  • Problem with the equipment

  • Hazard Report Number

  • Initiator

  • Date

  • Photo 1

  • Photo 2

  • Photo 3

Evaluate Operational Impact and Risk

  • Consequences of deferring action, risk associated with operating in its current defective condition - use Water Corporation risk matrix

  • Current Risk

Options

  • What investigations have taken place to date - cost, replacement availability, asset criticality? What is the current situation?

Recommendations

  • What is the preferred corrective action? Advantage of replacement / modification?

  • PM Order Number

  • Estimated date fix required

  • Estimated cost

  • Reviewed by

  • Date

ADR Entered into ACA

  • Entered by

  • Date

  • Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.