Title Page

  • Name of Organization

  • Copy No.

  • Conducted on

  • Prepared by

Planning

Hazard Identification

    Hazard
  • Describe Hazard

  • Hazardous Condition

  • Unsafe Behavior

  • Possible Accident Types

  • Please specify

  • Risk probability

  • Risk severity

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

  • 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

Completion

  • Approved by

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