Information

  • Conducted on

  • Prepared by

  • Location
  • General Information

  • Type of area

  • Nature of event

  • Contact Name and Number

  • Is power available

  • Was power disrupted?

  • Is property easily accessible by road?

  • Estimated number of people at the property

  • Drinking Water

  • Is the distribution system working (e.g. Tap water)?

  • Does the water appear to be contaminated (e.g. Dirty), or at risk of microbial or chemical contamination?

  • Is there an alternative water supply available?

  • Sewage, Waste and Asbestos

  • Is town sewage available?

  • Is there an on-site sewerage system available?

  • Is there a public health hazard from sewage or liquid waste?

  • Do people have access to functioning toilets?

  • Are additional toilets required

  • Is waste posing a public health risk

  • If yes what is the time frame of the public health risk?

  • Does any if the waste look like it contains asbestos?

  • Is it bonded or friable?

  • Add media

  • Will machinery create a public health risk (e.g. lawn mowers, vehicles, heavy equipment)?

  • Should asbestos handling information be disseminated?

  • Contact email:

  • Is a mass clean up required for all waste?

  • Comment

  • Add media

  • Food Safety

  • Premises Type:

  • Is the premises operating?

  • Has there been damage to the premises

  • Add media

  • Is suitable refrigeration available?

  • Did you seize any food?

  • Details:

  • Other specific comments (e.g cleaning required)

  • Other

  • Personal Hygiene

  • Are there adequate facilities for personal washing, cleaning and bathing?

  • Is there a need for personal hygiene products to be supplied?

  • Shelter

  • Is the premises overcrowded?

  • Are residents camping?

  • Vector, vermin and animal control

  • Are there exposed piles of refuse, dead animals, or putrescible material?

  • Add media

  • Are there potential mosquito breeding sites?

  • Add media

  • Are flies, Mosquitos or other insect pests in numbers to cause concern?

  • Do residents require insect repalent?

  • Are rodent populations visibly present?

  • Are roaming animals an issue?

  • Detail:

  • Chemical Hazards

  • Are there any stored chemicals that may pose a public health risk?

  • Add media

  • Have any chemicals been released?

  • Add media

  • Priority Areas

  • Drinking Water

  • Food Safety

  • Personnel Hygiene

  • Sewage

  • Solid waste management

  • Asbestos

  • Shelter

  • Vector and vermin control

  • Chemical Hazards

  • All other comments

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.