Information

  • Job Site Address

  • Job Number

  • Work Safe Certified Surveyor

  • Conducted on

  • Picture of the outside of job site

  • Age of the house

  • Laboratory being used for testing

  • What lab?

Property Information

  • Building Use

  • Property Type

  • What level floor

  • Is there a balcony?

  • Property Occupancy

  • Cause Of Work

  • General Property Condition

  • Risk to health

  • Other job site notes and hazards

Safety and ppe

  • What steps are being taken to secure area?

  • PPE used

  • what other ppe

  • Sample
  • Room /Area Name

  • Room Photos *Room overview at least 3 shots of the room.

  • Area / Level

  • Location Sampled

  • Are there multiple layers

  • What material is the ceiling?

  • Material Tested

  • Does the flooring run under anything (cabinets, vanity’s, material)

  • Does the flooring run under anything (cabinets, vanity’s, material)

  • Does the flooring run under anything (cabinets, vanity’s, material)

  • Time of sample taken

  • Sample numbers

  • How Many Samples Taken?

  • Has the sample location been marked and sealed

  • Has the sample location been marked on a map

  • Reasoning for taking the sample

  • Reasoning for taking from that location

  • Description of the sample taking process

  • What steps was taken to make the process adhere to ALARA

  • picture of sample locations

  • SQFT of sampled material

  • SQFT of sampled material to be removed

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.