Information
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Prepared by:
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For third shift: Select the date when your shift start
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Date
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Select shift
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All of the following should be checked during the inspections (if applicable) *Eyewash/Showers (w/cards) *Guards *Electrical Hazards *PPE *Slip, Trip & Fall Hazards *Lighting *House Keeping *Trash cans *Fire Extinguishers *First Aid. Any adverse conditions found?
- No adverse condition found during inspection
- Yes; adverse condition found
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Take picture of the adverse condition(s) or provide additional comments
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Notification to Miner’s Working in the Area?
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Notification to Supervisor or Manager?
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Enter the Date when adverse conditions were corrected. Add any comment (if needed)
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Briefly describe correction:
Additional Comments (if any)
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Add any comment (if needed)
