Information

  • Project Name and/or Job Number

  • Site Address

  • Conducted on

  • Business Representative

  • Location
  • Document No.

Details

Worker / Contractor's Details and History

  • Company Name (if applicable)

  • Name

  • How many H&S breaches previously?

  • Is there a policy or Safe Operating Procedure/Safe Work Method Statement available for the job?

  • Raise as Health and Safety matter at next meeting.

  • Has the Worker been inducted and trained to this standard and training records are available?

  • Attach Worker information to file

Details of WH&S Breach

  • Date and time of breach

  • Type of breach

  • State Breach

  • Enter specific details of breach -

  • Add any relative photos / media

Signature

  • Is this the 3rd and final stike?

  • I understand that this is my 3rd and final strike and under the businesses 3 strike policy I am no longer permitted to work on any of their job sites.

  • Schedule Worker in for re-training and increased monitoring.

  • I hereby accept that the details on this form are true and correct and will rectify my actions to conform with all procedures and policies.
    I understand that the business only allows 3 strikes before I will no longer being able to access their sites.

  • Person accepting strike

  • Person filling out form and witnessing

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.