Information
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Document No.
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Conducted on
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Prepared by
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Company
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Location
LIFE CRITICAL TOTAL
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Work Platforms & Scaffolding
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Corrective Action Due Date:
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Fire Prevention & Protection
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Corrective Action Due Date:
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Electrical
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Corrective Action Due Date:
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Confined Spaces
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Corrective Action Due Date:
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Plant & Equipment
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Corrective Action Due Date:
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Working at Height
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Corrective Action Due Date:
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Lifting Operations
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Corrective Action Due Date:
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Excavations & Trenching
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Corrective Action Due Date
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HEALTH & WELFARE TOTAL
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Work Area
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Corrective Action Due Date:
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Trash Containers/Disposal
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Corrective Action Due Date:
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Rest Areas
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Corrective Action Due Date:
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Drinking Water
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Corrective Action Due Date:
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Toilets/Washing Facilities
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Corrective Action Due Date:
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First Aiders/First Aid Kits
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Corrective Action Due Date:
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WORK ENVIRONMENT TOTAL
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Heat Stress
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Corrective Action Due Date:
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Noise
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Corrective Action Due Date:
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Illumination
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Corrective Action Due Date:
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Dust Suppression/Control
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Corrective Action Due Date:
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Object/Line of Fire Hazards
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Corrective Action Due Date:
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Access/Egress
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Corrective Action Due Date:
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Traffic Management/Barricades
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Corrective Action Due Date:
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Safety & Road Signage
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Corrective Action Due Date:
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EQUIPMENT & PROCEDURES TOTAL
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Personal Protective Equipment
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Corrective Action Due Date:
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Hand & Power Tools
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Corrective Action Due Date:
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Management & Supervision
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Corrective Action Due Date:
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COSHH
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Corrective Action Due Date:
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People (Behaviors)
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Corrective Action Due Date:
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Method Statements/Risk Assessments
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Corrective Action Due Date:
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Permit to Work
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Corrective Action Due Date:
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OTHER TOTAL
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Observation #1:
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Corrective Action Due Date:
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Observation #2:
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Corrective Action Due Date:
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Observation #3:
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Corrective Action Due Date:
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ADDITIONAL PHOTOS
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REPORT SUMMARY
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Initial Action Report (IAR) Issued?
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Reason for IAR:
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Non-Compliance Report Issued?
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Reason for Non-Compliance Report:
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Was there a Work Stoppage?
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Reason for Work Stoppage:
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Contractor Representative Signature:
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Supervising Consultant Signature:
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Parsons Representative Signature:
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Other Comments
VERIFICATION & CLOSEOUT (Developers Only):
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Contractor Signature/Date/Comments:
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Supervising Consultant Verification Signature/Date/Comments:
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Parsons Review Signature/Date/Comments:
