Non-Conformance/Hazard Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Part A: Complete items 1 - 5 and give to Supervisor, Quality Officer or Safety Manager

• (1) Brief description of Non-Conformance or Health and Safety issue

• Add media

  Media

• (2) Location of Non-Conformance in workplace

• Add media

  Media

• (3) Time / Date Non-Conformance/Hazard identified

• Select date

  Date

• (4) Recommended remedial action to ensure workplace health and safety / compliance

• Recommended completed date

  Date

• (5) Please note: This report does not imply that all other conditions and work practices are acceptable

• Reported by

• Add signature

  Sign

• Received by:

• Add signature

  Sign

Part B: Description of remedial action taken to ensure workplace health and safety/compliance

• Has the issue been satisfactory addressed

  Yes

  No

• Completed date

  Date

• Reporting persons signature

• Add signature

  Sign