Corrective Action Request (CAR)

• CAR Register Number:

• The CAR # should be in the following format yyyy.mm.dd-*** (where *** is number i.e. 001, 002, etc. see below.)

  

• Conducted on:

  Date
• Site Location
  Address

• Prepared by:

• Position:

  Project Manager

  Site Manager

  Site Foreman

  Safety Manager

  Other

• Please give position of person preparing this document

Details:

• Person &/or Company responsible for action:

• How was the issue identified or reported?

  Select General Observation Accident/Incident Report Email Phone Complaint Internal Audit External Audit Other

  • General Observation
  • Accident/Incident Report
  • Email
  • Phone
  • Complaint
  • Internal Audit
  • External Audit
  • Other

• Reported by (position):

  Select Site Staff Worker Client Contractor Public Other

  • Site Staff
  • Worker
  • Client
  • Contractor
  • Public
  • Other

• Reported by (name):

• Description of the issue:

• Photo of the issue:

  Media

Risk Rating:

• TKL Risk Matrix:

  

• Risk Rating based on the TKL Risk Matrix:

  Select 1. High 2. Medium 3. Medium 4. Medium 5. Low 6. Low N/A (for issues that do not concern safety)

  • 1. High
  • 2. Medium
  • 3. Medium
  • 4. Medium
  • 5. Low
  • 6. Low
  • N/A (for issues that do not concern safety)

Risk Management:

• TKL Risk Control:

  

• CORRECTIVE ACTION TYPE (What type of controls are to be implemented to rectify the issue &/or prevent a repeat of the issue in future?):

  Select 1. Eliminate the risk (most effective control) 2. Substitute with a safer alternative 3. Use engineering controls 4. Redesign to reduce risk 5. Isolate people from risk 6. Use administrative procedures 7. Use (PPE) personal protective equipment (least effective control) N/A for issues that do not concern safety

  • 1. Eliminate the risk (most effective control)
  • 2. Substitute with a safer alternative
  • 3. Use engineering controls
  • 4. Redesign to reduce risk
  • 5. Isolate people from risk
  • 6. Use administrative procedures
  • 7. Use (PPE) personal protective equipment (least effective control)
  • N/A for issues that do not concern safety

• CORRECTIVE ACTION DETAILS (Describe in detail what rectification action is to be taken by the person &/or company):

• CORRECTIVE ACTION DATE (Action is to be completed by no later than this date & time):

  Date

• Person preparing this form:

  Sign