NetworkRail - Safety Representative Inspection Template

• Prepared by

• To (Employer or representative)

• From (Employer or Representative (s)

• Conducted on

  Date
• Location
  Address

• INSTRUCTIONS
  
  1. Answer on the questions below.
  2. Add photos and notes by clicking on the paperclip icon
  3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority and due date
  4. Complete audit by providing digital signature
  5. Share your report by exporting as PDF, Word, Excel or Web Link

FORM A

• Date and Time of Inspection :

  Date

• Area of Work Place Inspected :

FORM B

• NOTE : Notification to the Employer (or his representative) of condition of working practices considered to be unsafe or unhealthy and arrangements for welfare at work considered to be unsatisfactory

• Click Add Condition to start listing down condition(s)

CONDITION

• Particulars of matter(s) notified to employer or his representative (including location where appropriate)

• Remedial Action Taken?

  Yes

  No

NAMES AND SIGNATURES TAKING PART IN THE INSPECTION

• NOTE : This record does not imply that the conditions are safe and healthy or that the arrangements for welfare at work are satisfactory

• Safety Representative Name & Signature

  Sign

• Employer or Representative Name & Signature

  Sign