FSG- Service Inspection

• Service Technician

• Work order / Job number

• Client / Site

• Conducted on

  Date

• Prepared by

• Other Personnel

Employee Work Practices

• Date/Time of inspection

  Date

• Immediate Observations

• Work area safe and secure? (Cones, caution/danger tape, Etc)

• JHA complete and Accurate?

  Yes

  No

  N/A

• LOTO Utilized

  Yes

  No

  N/A

• 12 Cal / Hot gloves Utilized?

  Yes

  No

  N/A

• Correct PPE in use?

  Yes

  No

  N/A

• PPE in good Condition?

  Yes

  No

  N/A

• Imminent Danger to Employees or Customers?

  Safe

  At Risk

  N/A

• Was Immediate Action taken?

Incident Investigation

• Was there an Incident/Accident or safety Violation?

  No

  Yes

• Unsafe Act

  No

  Yes

• Unsafe Condition

  No

  Yes

• Was there a failure by the employee to : <br><br>Plan, Direct, Organize?

  No

  Yes

• Plan

  No

  Yes

• Direct

  No

  Yes

• Organize

  No

  Yes

• Are there Indirect Causes due to lack of: <br>Training , Resources, Belief?

  No

  Yes

• Training

  Yes

  No

  N/A

• Resources

  Yes

  No

  N/A

• Belief

  Yes

  No

  N/A

• Signature

  Sign