Opportunity for Improvement

Employee to complete front page

• Area for improvement

  Select Safety Quality Environment Tailgate New idea/ Improvement Health Audit actions: Safety Audit actions: Quality Audit actions: Environment Other

  • Safety
  • Quality
  • Environment
  • Tailgate
  • New idea/ Improvement
  • Health
  • Audit actions: Safety
  • Audit actions: Quality
  • Audit actions: Environment
  • Other

• Name:

• Incident time/ date:

  Date

• Occupation:

• Department:

• Name of person filling out form:

• Start time:

  Date

• Asset no.

What happened? What's the issue? What was good? What's the improvement?

• What needs to be done?

• Who else was involved/ witnesses?

Plan of site/ scene/ accident or Additional notes

• Plan:

  Drawing

• Notes:

Manager to complete.

• Risk score:

  Low

  Medium

  High

  Extreme

• SQTE checked rush score and agree:

• SQTE signature

  Sign

• Regulatory authority notified (where applicable):

• Estimated cost of remedial/ damages:

• Hazard: Is this a generic hazard or specific to this site?

  Generic

  Site specific

  N/A

• Description of injury:

• Body part:

• Current status:

  Not fit for work

  Alternative Duties

  Fully fit for work