Physical Conditions inspection RLGM

• Complex - Area of Inspection

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

• Persons Conducting Inspection

Supervisor

• Add the Supervisor in charge of the area

Name

• Name

• Number

Employees

• Add the The name(s) of employees you had contact with during your tour.

Name

• Name

• Number

Physical Conditions Observed

• Add an observation

Choose one, observation

• Choose one

  Select ventilation ground support lifting barricade housekeeping Cyanide

  • ventilation
  • ground support
  • lifting
  • barricade
  • housekeeping
  • Cyanide

• Add media

  Media

• Observation

• Supervisor Responsible

• Level of Risk<br>

  low

  medium

  high

  extreme

Acknowledgements

• Assessment carried out by

  Sign

• Name