Sections

Data Collection

Description of Deficiency

Item to Correct
Facility

Floor

Room Number

Is 'Responsible Leader' Plant Operations?

Who?

Description of Deficiency

Photo

Life Safety Priority

Type

Corrected On-Site?

New Items

Questions or Follow Up Items

Question or Follow Up Items

Questions

Question:

Who are you responding to?

Smart Fields

Sign this Field

Great work!

Dynamic Fields

Equipment

Is there any faulty equipment?

Equipment

Model #

Serial #

Is anyone at fault?

Who?

Person

Name

Employee #

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.