Description of Problem

Describe what is wrong with the equipment:

Touch here to describe problem:

How was the equipment being used at the time?

Describe how it was being used at the time:

Was this the proper equipment for this work?


Have you had the same problem before?

If yes, provide additional detail:


Enter any pertinent information not covered above:

Include pictures of problem if applicable: select yes, then click on media to add pictures.

Sign Off
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.