Information

  • Document No.

  • Date/ Time

  • Prepared by

Directions

  • Enter any Directions brought to attention...

  • Direction
  • Select CC or MHBM

  • CC Facility

  • MHBM facility

  • Room no./location

  • Type of media...

  • Photo...

  • Drawing

  • Detail of direction

  • Requested on...

  • Signature of requestor

Variations

  • Enter any variations brought to attention...

  • Variation
  • Select CC or MHBM

  • CC Facility

  • MHBM facility

  • Room no./location

  • Type of media...

  • Photo...

  • Drawing

  • Detail of variation

  • Requested on...

  • Signature of requestor

Delays

  • Enter any delays brought to attention...

  • Variation
  • Select CC or MHBM

  • CC Facility

  • MHBM facility

  • Room no/location

  • Type of media...

  • Photo...

  • Drawing

  • Detail of delay

  • Was the customer or contact advised of the delay?

  • Person who was advised on delay...

  • Comments made..

  • Estimated date of resolution

  • ADVISE SUPERVISOR OR OPERATIONS MANAGER IMMEDIATELY

Safety/Hazard Identification

  • Does the identified hazard have the potential to cause harm

  • Identified hazards

  • Hazard
  • Determine risk level from matrix

    risk matrix
  • Determine the consequence and likelihood from the risk matrix and select appropriate risk level

  • If possible, immediately implement control measures to prevent injury, i.e. unprotected floor penetration - place a barricade and/or safety observer until the person in control of site has been notified and responded.

  • Photo of hazard

  • Immediate and Recommended controls

  • Has the issue been reported/escalated

  • Reported to/further detail

  • Date and time of advice sent

  • Photo of hazard

  • Recommended controls

  • Has the issue been reported/escalated

  • Reported to/further detail

  • Date and time of advice sent

  • No further action necessary

  • Select CC or MHBM

  • CC Facility

  • MHBM facility

  • Room or location

Completion

Completion

  • Has this report been sent to the appropriate person

  • Report completed by...

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.