Title Page

  • Site conducted

  • Prepared by

  • Conducted on

  • Department

  • Which Maint group

  • Which group

  • Which group

  • Which group

  • Which group

  • Which group

  • Location

    Hazard report (1 point)
  • Select Shift

  • What part of shift was the hazard found

  • How many days into the rotation was the hazard found (effected crew)

  • Was equipment involved

  • Equipment type and numbers

  • Is this a Critical risk report or Standard hazard report

  • Which Critical Risk would this be classified under?

  • Select the PTW program

  • Select type of energy

  • Description of condition or practice

  • Photo of condition

  • Immediate action(s) taken

  • Reported to who

  • What controls

  • Comment required

  • Hazard Classification

  • Is this hazard cyanide related

  • Description of condition or practice

  • Photo of condition

  • Immediate action(s) taken

  • Reported to who

  • What controls

  • What controls were added

  • Was work stopped to mitigate the hazard?

  • Describe resolution

  • Establish a long term solution to eliminate a hazard (2 points)
  • Please ensure the 1 point section is fully competed as well

  • What steps have been established to sustain the corrective actions

  • What measurement will be used to know the control is in place and effective (long term)

  • Who is the control owner

  • Notify Committee for review

  • New Critical risk topic (6 points)
  • Complete description of condition or practice requiring a new CR topic

  • Photo(s) of condition

  • What department(s) would benefit the most from this CR topic

  • Submit Topic for review

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