Take photograph/s relating to Safety Improvement Opportunity:

In your opinion what is the level of risk to employees or others?

Briefly describe the SIO/issue:

Name of Line manager:

Have your reported this to your line manager?

If necessary, has the immediate risk been removed or made safe?

Any Suggested Improvements/Other Comments?

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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.