Information

  • Report of Safe / Unsafe Acts and Conditions

  • Document No.

Report of Safe / Unsafe Acts and Conditions

  • Department Name :

  • Departmental Manager:

  • Inspection completed by :

  • Date Completed :

  • Conditions :

  • Weather :

  • External Temperature

  • Do you have a copy of the last SUSA inspection of this area ?

  • Have all of the issues raised on the previous SUSA been closed out ? ( if no ensure the issues are included again in this SUSA )

SUSA Inspection Informaton

Unsafe Acts / Conditions

  • Description of Unsafe Act / Condition No. 1

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 2

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 3

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 4

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 5

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 6

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 7

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 8

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 9

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Description of Unsafe Act / Condition No. 10

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Add another Unsafe Act

  • Description of Unsafe Act / Condition

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Add another Unsafe Act

  • Description of Unsafe Act / Condition

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Add another Unsafe Act

  • Description of Unsafe Act / Condition

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Add another Unsafe Act

  • Description of Unsafe Act / Condition

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Add another Unsafe Act

  • Description of Unsafe Act / Condition

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

  • Add another Unsafe Act

  • Description of Unsafe Act / Condition

  • Potential Accident or Injury

  • Number of people affected

  • Seriousness

  • Cause

  • Source

  • Recommended fix

  • Actual Fix

Additional Information

  • Additional Comments

  • Please add any relevant photographs from the SUSA Inspection

Inspection Sign Off

  • Inspection Completed By :

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.