KGM Unsafe Act, Unsafe Condition & Substandard Equipment Report

• Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and /or correct these potential accidents/incidents immediately. Please complete this form as a means to report these unsafe acts/conditions/substandard equipment.

• Ce sont des conditions de travail dangereuses, des habitudes professsionnelles dangereuses, des utilisations inadéquates des équipements ou l’utilisation de materiel malfonctionnant pouvant causer des blessures au travail. C’est une responsabilité de tous de signaler et/ou corriger ces potentialités d’accident/incident immediatement. Veuillez completer ce formulaire comme un moyen de signaler ces situations

• Unsafe Observation Type

  Select Unsafe Act / Act dangereux Unsafe Condition / condition dangereuse Unsafe Equipment / Equipement dangereux Unsafe Use of Equipment / Usage des équipements dangereux

  • Unsafe Act / Act dangereux
  • Unsafe Condition / condition dangereuse
  • Unsafe Equipment / Equipement dangereux
  • Unsafe Use of Equipment / Usage des équipements dangereux

• Date & Time

  Date

• Location

• Prepared by

• Who was involved (job title) / Personnes impliquees (titre)

• Département/Department or Company / Compagnie

  Select

• Description of unsafe act, condition, equipment / Description de l’acte dangereux, condition dangereuse, equipment dangereux

• Immediate Actions taken / Actions immediate prises

• Reported to

  Select Supervisor Foreman Superintendant Manager Safety Control Room

  • Supervisor
  • Foreman
  • Superintendant
  • Manager
  • Safety
  • Control Room

ADDITIONAL INFORMATION

• Additional Information Related to the Unsafe Observation

• Document Number