Choose which publication you would like to make a change to.

Date of Publication

Revision Number or Latest Change Date

Is your change due to an emergency or safety related incident?

If your change is due to an emergency or safety related issue, did you fill out a HIRS form?

Page Number

Major / Sub Paragraph Title or Chart / Figure Number

Text or figure as presently reads (list what is considered to be incorrect or missing)

Change to Read (Describe the desired changes)

Rationale (Provide reason or additional comments for this recommendation)

Submitted by
Reviewed by
Reviewer with approval/disapproval authority:
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.