Service Inspection FSG

• Work order #

• Tech name

• Employee #

• Client / Site

• Conducted on

  Date

• Chris

• Ryan
• Location
  Address

• Other Personnel

• Yes

  No

  N/A

Audit

• Immediate Observation / Imminent Danger?

  Safe

  At Risk

  N/A

• JHA is complete and accurate

  Yes

  No

  N/A

• LOTO has been utilized?

  Yes

  No

  N/A

• Means of disconnect available?

  Yes

  No

  N/A

• Is van Clean?

  Yes

  No

  N/A

• Is employee wearing all required PPE?

  Yes

  No

  N/A

• 12 cal suit available?

  Yes

  No

  N/A

• 12 cal suit in good repair?

  Yes

  No

  N/A

• Fire extinguisher in Vehicle?

  Yes

  No

  N/A

• First Aid/Body fluid kit in vehicle?

  Yes

  No

  N/A

• Attach photos of Job

  Media

• Notes:

• Signature of Tech

  Sign

• Inspector signature

  Sign

• Other Signature

  Sign

Incident Investigation

• Was there an Incident/Accident or safety Violation

  Yes

  No

• Was there a failure by the Employee to : <br>Plan<br>Direct<br>Organize

  Yes

  No

• Plan

• Direct

• Organize

• Are there indirect causes due to lack of:<br><br>Training - Resources - Belief

  Yes

  No

• Training

• Resources

• Beliefs