Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Department
Pre-Emptive Safety Event
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Employee Name:
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What was Observed:
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Describe Your Observation in Detail
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Describe What You Did to Improve, Correct or Respond to the Observation
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Did Your Actions Correct the Observation
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If No, How do you "Suggest" the Observation be Corrected
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Employee Signature
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Supervisors Signature