Title Page

  • Facility/ Line Segment

  • Conducted on

  • Prepared by

  • Location
  • Companies Line

  • District/Area

  • Work order Required

  • Yes

  • If "yes" please explain

  • No

  • AFE #

  • Date Found

  • Found by

  • Reported To

  • Date Reported

  • Potentially Hazardous Condition?

  • Yes

  • Situation must be immediately reported, investigated, and appropriate action implemented.

  • No

  • Has the condition been repaired?

  • Comments:

  • LAT/LONG of Location
  • Description

  • Condition Found

  • Immediate Action Taken

  • Brief Description/Scope of Work

  • Picture(s)

  • Signature

  • Date

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.