Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Incident Description

  • National, Contractor, Sub-contractor, Employee?

  • Was there any injury to person/s?

  • Was there any damage to property?

  • Has the zone / area foreman been informed about the SWA?

  • Can the work be safely completed after remedial action?

  • Area / Zone description

  • Short description of the incident.

  • Photo of the area / incident

  • Name and signature of person/s involved?

  • Name and signature of person/s involved?

  • Name and signature of person/s involved?

  • Name and signature of person/s involved?

  • Name and signature of person/s involved?

  • Name and signature of person/s involved?

Actions taken by person leading the SWA?

  • Stop work immediately?

  • Make area concerned safe?

  • Informed relevant managers / supervisors?

  • Informed persons involved why SWA action has been taken?

  • Performed a safety stand down with all persons involved and witnesses?

  • Topic covered during the SWA stand down.

  • Acquired all relevant information and details from person/s involved?

  • Submit SWA immediately after stand down for record / filing purposes?

  • Resources made available to mitigate risks in place?

Actions required for resolution of incident.

  • List actions to be taken.

  • Name and signature of person responsible for action.

  • Date and time for action to be completed.

  • Has work continued after SWA stand down?

  • How was the situation resolved so work could resume safely?

  • Potential consequences if work was not stopped?

  • Time when work commenced

Recommendations

Zone / Area foreman or HSE officer acknowledgment

  • Add signature

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