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
Incident
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Explain what is faulty, broken, or defective on the machine:
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What is the overall cause of the faulty, broken, or defective equipment?
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Can the pump still operate safely?
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Did you lock and tag the Vehicle/Machine to ensure other employees do not operate the machinery?
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Did you Inform Management?
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Who did you inform?
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Why didn't you inform management?
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I acknowledge this information to be truthful to the best of my ability.
