Report of Safe / Unsafe Acts and Conditions

• Report of Safe / Unsafe Acts and Conditions

• Document No.

Report of Safe / Unsafe Acts and Conditions

• Department Name :

• Departmental Manager:

  Select Phil Gould Simon Hutchison Nick Tunnicliffe Vicky Conroy Steve Clarke Mark May Simon Perkins Chris Foster Robert Matsuzak Simon Wood Gavin Beardmore

  • Phil Gould
  • Simon Hutchison
  • Nick Tunnicliffe
  • Vicky Conroy
  • Steve Clarke
  • Mark May
  • Simon Perkins
  • Chris Foster
  • Robert Matsuzak
  • Simon Wood
  • Gavin Beardmore

• Inspection completed by :

• Date Completed :

  Date

• Conditions :

  Dry

  Wet

  Snow

  Ice

• Weather :

  Windy

  Calm

• External Temperature

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

  Yes

  No

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

  Yes

  No

SUSA Inspection Informaton

Unsafe Acts / Conditions

• Description of Unsafe Act / Condition No. 1

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 2

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 3

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 4

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 5

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 6

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 7

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 8

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 9

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Description of Unsafe Act / Condition No. 10

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Add another Unsafe Act

  Yes

  No

• Description of Unsafe Act / Condition

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Add another Unsafe Act

  Yes

  No

• Description of Unsafe Act / Condition

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Add another Unsafe Act

  Yes

  No

• Description of Unsafe Act / Condition

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Add another Unsafe Act

  Yes

  No

• Description of Unsafe Act / Condition

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Add another Unsafe Act

  Yes

  No

• Description of Unsafe Act / Condition

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

• Add another Unsafe Act

  Yes

  No

• Description of Unsafe Act / Condition

• Potential Accident or Injury

  Select Slip / Trip / Fall Struck By Struck Against Caught in / between Lifting Over Exert Toxic Substances Suffocation Electric Shock Explosion Fire Vehicle Injury Collapse Confined Space Other

  • Slip / Trip / Fall
  • Struck By
  • Struck Against
  • Caught in / between
  • Lifting
  • Over Exert
  • Toxic Substances
  • Suffocation
  • Electric Shock
  • Explosion
  • Fire
  • Vehicle Injury
  • Collapse
  • Confined Space
  • Other

• Number of people affected

  1 - 4

  5 - 8

  9 - 12

  > 12

• Seriousness

  1. Minor Injury

  2. Major Injury

  3. Serious Injury

  4. Fatal Injury

• Cause

  Select Careless Unaware Safety Equipment Work Equipment Material Instruction Workers Time Cost Inconvenient work Deffective

  • Careless
  • Unaware
  • Safety Equipment
  • Work Equipment
  • Material
  • Instruction
  • Workers
  • Time
  • Cost
  • Inconvenient work
  • Deffective

• Source

  Select Me My Company Contractor Worker Manager Designer Other

  • Me
  • My Company
  • Contractor
  • Worker
  • Manager
  • Designer
  • Other

• Recommended fix

  Select Do Stop Replace Repair Obtain / Add Instruct Communicate Test / Inspect Guard Mark / Sign Reasign Move

  • Do
  • Stop
  • Replace
  • Repair
  • Obtain / Add
  • Instruct
  • Communicate
  • Test / Inspect
  • Guard
  • Mark / Sign
  • Reasign
  • Move

• Actual Fix

  Fixed

  Temporary

  Reported

  Acceptable

  Nothing done

Additional Information

• Additional Comments

• Please add any relevant photographs from the SUSA Inspection

  Media

Inspection Sign Off

• Inspection Completed By :

  Sign