Information
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Document No.
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Client
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Client Contact Name
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Title
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Contact #
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Conducted on
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Location
Complaint Response Checklist
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How was the safety complaint received?
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Who reported the complaint?
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Describe allegation being made
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Has this condition been brought up to Client Company?
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If yes, to whom?
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Does hazard exist?
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How long has hazard existed?
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Can hazard be corrected immediately?
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If "no", by when will hazard be corrected?
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Who is responsible for corrective action?
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Safety Specialist Notes
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Safety Specialist Signature
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Client Contact Signature
