Reporting of Unsafe Acts/Behaviours onsite

• Report of unsafe Act/Behaviour

  Date

• Site

  Blakes Cross

  M1

  Huntstown

Report of Unsafe Act/Behaviour

• Location of observation

• Departmental Manager:

  Sign

• Inspection completed by :

Unsafe Acts / Behaviours

• Description of Unsafe Act / Behaviour

• Potential Accident or Injury

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

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

• Number of people affected - Please details the number of people within the area that could have potential been affected by this Act/Behaviour

  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

  Driver

  Ace Staff member

  Contractor

  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 Comments

Inspection Sign Off

• Inspection Completed By :

  Sign