RB Visit Risk Assessment Form

• Audit Title

• Document No.

• RB audit

• Assessment conducted by: Rinaldo Bersanetti

• Customer Details:

• Site Address:
  Address

• On Site Contact name:

• Contact Number:

• Machine model:

• Machine Serial Number/VIN:

• Machine Hours:

• Reason for the visit:

• BersaResearch Inc.

Assessment

• This assessment is specific to an offsite machine visit by a Product Support Manager

• Have you reported to machine site reception or contact ?

  Yes

  No

  N/A

• Have you been made aware of local safety rules ?

  Yes

  No

  N/A

• Have you been made aware of any potential hazards ?

  Yes

  No

  N/A

• Will you be accompanied during all times at the site ?

  Yes

  No

  N/A

• Is the machine you will be visiting in a safe condition ?

  Yes

  No

  N/A

• Is the machine you are visiting in a safe location ?

  Yes

  No

  N/A

• Are you satisfied that you can undertake your role safely ?

  Yes

  No

  N/A

• If you have answered NO to any of the above then you must NOT proceed until sufficient actions have been taken to eliminate or significantly reduce the risk to an acceptable level. Once actions have been taken then repeat the risk assessment. If you are still out satisfied then contact your Manager.

• Signed:

  Sign