Chris Haefele

MCDGRPNZ See Say Do

You Report We Improve

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Use this Template

Information

Work Activity?
Location of work?
Reported by?
Reported to?
Conducted on

SEE SAY DO (YOU REPORT - WE IMPROVE)

REPORT CLASSIFICATION?
- A BETTER WAY
- IMPROVEMENT
- UNSAFE CONDITION
- UNSAFE BEHAVIOUR
WHO?
WHAT DID YOU OBSERVE (REPORT)?
POSSIBLE CONSEQUENCES?
YOUR SUGGESTED ACTION?

OFFICE USE ONLY

NEAR MISS
HAZARD
OFI
NCR
ISSUE OWNER (DIRECT)
ISSUE OWNER (INDIRECT)
GOLDEN RULE BREACH (YES / NO)
AGREED ACTION 1:
ACTION ASSIGNED TO?
ACTION DUE DATE?
AGREED ACTION 2:
ACTION ASSIGNED TO?
ACTION DUE DATE?
DATE ENTERED TO DATA BASE?
DATABASE ENTRY BY?

Chris Haefele

MCDGRPNZ See Say Do

You Report We Improve

Use this Template

Print as PDF

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