RAC Environmental Health & Safety Alert

• Conducted on

  Date

• Prepared by

• Location

  Select Lakes Manufacturing Lakes Warehouse Hudson Rd. HQ Lab Reno Headquarters

  • Lakes Manufacturing
  • Lakes Warehouse
  • Hudson Rd.
  • HQ Lab
  • Reno
  • Headquarters

• Alert No

• Type of Alert

  Select Injury Event Environmental Exposure Event (Chemical, Biological, Radiological) Lost Time Accident Motor Vehicle Collision Property Damage Hazard Identification Unsafe Acts Near Miss Electrical Incident Ergonomic (Strain / Sprain)

  • Injury Event
  • Environmental
  • Exposure Event (Chemical, Biological, Radiological)
  • Lost Time Accident
  • Motor Vehicle Collision
  • Property Damage
  • Hazard Identification
  • Unsafe Acts
  • Near Miss
  • Electrical Incident
  • Ergonomic (Strain / Sprain)

• Description of Incident

• Photo and/or Video

  Media

• Injury / Damage Description (Put N/A if not applicable)

Contributing Factors

• Asset

  Select N/A Equipment Failure Design Issues Insufficient Safety Devices / Guarding Inadequate Storage Inadequate Maintenance Inadequate Training Wrong Equipment for the Job Material / Equipment too Heavy / Awkward

  • N/A
  • Equipment Failure
  • Design Issues
  • Insufficient Safety Devices / Guarding
  • Inadequate Storage
  • Inadequate Maintenance
  • Inadequate Training
  • Wrong Equipment for the Job
  • Material / Equipment too Heavy / Awkward

• Environmental

  Select N/A Weather Temperature Surfaces (Damaged / Unstable Floor) Light Hazardous Substances Housekeeping Noise Vibration Layout / Design Dust / Fume Slip / Trip Hazard

  • N/A
  • Weather
  • Temperature
  • Surfaces (Damaged / Unstable Floor)
  • Light
  • Hazardous Substances
  • Housekeeping
  • Noise
  • Vibration
  • Layout / Design
  • Dust / Fume
  • Slip / Trip Hazard

• People

  Select N/A Fatigue Unsafe Practice Working Alone Procedure Not Followed / No Procedure Exists Drugs / Alcohol Time / Production Pressures Change of Routine Distraction / Personal Issues / Stress Lack of Communication

  • N/A
  • Fatigue
  • Unsafe Practice
  • Working Alone
  • Procedure Not Followed / No Procedure Exists
  • Drugs / Alcohol
  • Time / Production Pressures
  • Change of Routine
  • Distraction / Personal Issues / Stress
  • Lack of Communication

• Systems of Work

  Select N/A No / Inadequate Safe Work Policies and Procedures Work Process or Design No / Inadequate Risk Assessment Hazard not Identified Hazard not Reported Inadequate Training / Supervision No / Inadequate Controls Implemented

  • N/A
  • No / Inadequate Safe Work Policies and Procedures
  • Work Process or Design
  • No / Inadequate Risk Assessment
  • Hazard not Identified
  • Hazard not Reported
  • Inadequate Training / Supervision
  • No / Inadequate Controls Implemented

• Note other Contributing Factors if not listed

Preventative Measures and Corrective Actions

• Potentinal Hazards To Be Aware Of:

• Actions To Prevent Reoccurrence (Click on Action and Assign to Responsible Individual(s)

• Any Additional Information (Put N/A if Not Applicable)

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• Authorized By:

  Sign

• Date and Time

  Date