PDCA Template - Planning

• Name of Organization

• Copy No.

• Conducted on

  Date

• Prepared by

Hazard Identification

Hazard

• Describe Hazard

• Hazardous Condition

  Yes

  No

  N/A

• Unsafe Behavior

  Yes

  No

  N/A

• Possible Accident Types

  Select Trips/slips or falls Caught in or struck by moving machinery Transportation or vehicle-related accidents Fire or explosions Overexertion and repetitive stress injuries Other

  • Trips/slips or falls
  • Caught in or struck by moving machinery
  • Transportation or vehicle-related accidents
  • Fire or explosions
  • Overexertion and repetitive stress injuries
  • Other

• Please specify

  Yes

  No

  N/A

• Risk probability

  Low

  Moderate

  High

• Risk severity

  Low

  Moderate

  High

Recommended Corrective Action(s)

• Engineering controls

• Management controls

• Personal Protective Equipment

Recommended System Improvement(s)

• Specify recommended improvement(s)

Determination of Legal and other Requirements

Regulation/Requirement

• Name of regulation/requirement

• Reference #

• Area of the organization it impacts

• Interested parties

  Workers

  Shareholders

  Sub-contractors

  Regulatory groups

  Other

• Document stipulating the requirement/compliance obligation

• Responsible Person

• Source of information (can be indicated in a hyperlink or description format)

Objective Planning

Objective

• What is to be done?

• Resources required (e.g., financial, human, equipment & infrastructure)

• Responsible person

• Target date of completion

• Metrics for evaluation & indicators for monitoring

• Priority Level

  Low

  Moderate

  High

Completion

• Approved by

  Sign