Shawn's Test Template

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Employees Involved

Employee Involved

• Witnesses

Witness

• Location:

  Select Brooks Edmonton 45th Edmonton 98th Edmonton 3550 Edmonton 3620 Lloydminster Provost

  • Brooks
  • Edmonton 45th
  • Edmonton 98th
  • Edmonton 3550
  • Edmonton 3620
  • Lloydminster
  • Provost

• Supervisor

  Glen Martinka

  Murray Brost

• Supervisor

  Glen Martinka

  Murray Brost

• Supervisor

  Jeff Hartling

  Glenn Martinka

• Supervisor

  Colin Thalheimer

  Murray Brost

• Department:

  Machine Shop

  Office

  PC Pumps

  Shipping

  Stators

• Supervisor:

  Select Ross Brice Brett Davidson Bell Katoch Ivo Nevesely Colin Thalheimer Kevin Titus

  • Ross Brice
  • Brett Davidson
  • Bell Katoch
  • Ivo Nevesely
  • Colin Thalheimer
  • Kevin Titus

• Department:

  Assembly

  Engineering R&D

  Office

  Shipping/Receiving

  Warehouse

• Supervisor:

  Select Billy Ambrose John Freeman Javier Garcia Greg Penkala Kevin Titus Murray Brost

  • Billy Ambrose
  • John Freeman
  • Javier Garcia
  • Greg Penkala
  • Kevin Titus
  • Murray Brost

• Date/Time of Occurrence

  Date

• Date of Report

  Date

• Date of Investigation

  Date

• Type of Incident

  Select Near Miss Property Damage Injury Environmental

  • Near Miss
  • Property Damage
  • Injury
  • Environmental

• Potential Incident

  Select Injury Property Damage Environmental

  • Injury
  • Property Damage
  • Environmental

• Risk Level

• Near Miss Pictures

  Media

• Damaged Item

• Cost ($) est.

• Property Damage Pictures

  Media

• Body Part Injured

  Select Head Face Neck Back Arm Hand Chest Abdomen Pelvis Leg Foot

  • Head
  • Face
  • Neck
  • Back
  • Arm
  • Hand
  • Chest
  • Abdomen
  • Pelvis
  • Leg
  • Foot

• Treatment Type

  First Aid

  Medical Aid

• Name of the First Aider

  Select Self-Administered Billy Ambrose Cody Rogers Jojo DeCastro Yong Xie Daniel McLaughlin Kyle Mielnichuk Andre Poirer Mike Sadurski Colin Thalheimer Javier Garcia Smmamunur Rashid Alejandro Roldan Goran Lazov Susan Yuan Vishal Patel John Freeman Peter Smith Christy Hunt Rita McCabe John Small Evelyn Anaya Willard Lawrence

  • Self-Administered
  • Billy Ambrose
  • Cody Rogers
  • Jojo DeCastro
  • Yong Xie
  • Daniel McLaughlin
  • Kyle Mielnichuk
  • Andre Poirer
  • Mike Sadurski
  • Colin Thalheimer
  • Javier Garcia
  • Smmamunur Rashid
  • Alejandro Roldan
  • Goran Lazov
  • Susan Yuan
  • Vishal Patel
  • John Freeman
  • Peter Smith
  • Christy Hunt
  • Rita McCabe
  • John Small
  • Evelyn Anaya
  • Willard Lawrence

• Recordable

• Lost Time

• First Missed Day

  Date

• Days Missed

• Injury Pictures

  Media

• Name of Chemical Released

• Reported to Authorities?

• Authority and contact information.

• Environmental Pictures

  Media

• Description

• Comments

• Signature

  Sign

Premises

• Were the premises a factor in the Incident?

  Yes, they were a factor.

  No, not a factor.

• Adequate but not used.

  No longer adequate

  Never adequate

• Was the employee suitable?

  Employee was suitable.

  Employee is no longer suitable.

  Employee was never suitable.

• Why was the employee no longer suitable?

  Select Resulting from a change in the worker. Resulting from a change in the task. Resulting from a change in the environment.

  • Resulting from a change in the worker.
  • Resulting from a change in the task.
  • Resulting from a change in the environment.

• Issue was previously identified.

• Notes

• Why was the employee engaged in a task for which they were unsuitable?

• Issue was previously identified.

• Notes

• Was the incident the result of intentional or unintentional circumstances.

  Unintentional

  Intentional

• Were they following accepted procedure, mistaken about the procedure, violating the procedure?

  Standard Behaviour

  MIstaken understanding

  Violation

• Issue was previously identified.

• Notes

• Was the incident the result of a lapse or a trip?

  Lapse

  Slip

• Cause of the lapse?

  Select Distracted? Unfit?

  • Distracted?
  • Unfit?

• Issue was previously identified.

• Cause of the slip?

  Select Ergonomics? Housekeeping? Hazard Controls?

  • Ergonomics?
  • Housekeeping?
  • Hazard Controls?

• Issue was previously identified.

• Notes

• What changed to make the premises inadequate?

  Select Security Health Impacts Design Changes Maintenance Demolition

  • Security
  • Health Impacts
  • Design Changes
  • Maintenance
  • Demolition

• Issue was previously identified.

• Notes

• Why is it inadequate?

  Select Security Health Impacts Design Changes Maintenance Demolition

  • Security
  • Health Impacts
  • Design Changes
  • Maintenance
  • Demolition

• Issue was previously identified.

• Notes

Plant and Substances

• Were the plant or substances used a factor in the Incident?

  Yes, they were a factor.

  No, not a factor.

• Was the plant adequate?

  Adequate but not used.

  No longer adequate

  Never adequate

• Was the employee suitable?

  Employee was suitable.

  Employee is no longer suitable.

  Employee was never suitable.

• Why was the employee no longer suitable?

  Select Resulting from a change in the worker. Resulting from a change in the task. Resulting from a change in the environment.

  • Resulting from a change in the worker.
  • Resulting from a change in the task.
  • Resulting from a change in the environment.

• Issue was previously identified.

• Notes

• Why was the employee engaged in a task for which they were unsuitable?

• Issue was previously identified.

• Notes

• Was the employee competent?

  Employee was competent.

  Employee was no longer competent.

  Employee was never competent.

• Why was the employee no longer competent?

  Resulting from a change in the worker.

  Resulting from a change in the task.

  Resulting from a change in the environment.

• Issue was previously identified.

• Notes

• Why was the employee engaged in a task for which they were not competent?

• Issue was previously identified.

• Notes

• Was the incident the result of intentional or unintentional circumstances.

  Unintentional

  Intentional

• Were they following accepted procedure, mistaken about the procedure, violating the procedure?

  Standard Behaviour

  MIstaken understanding

  Violation

• Issue was previously identified.

• Notes

• Was the incident the result of a lapse or a trip?

  Lapse

  Slip

• Cause?

  Select Distracted? Unfit?

  • Distracted?
  • Unfit?

• Cause?

  Select Ergonomics? Housekeeping? Hazard Controls?

  • Ergonomics?
  • Housekeeping?
  • Hazard Controls?

• Issue was previously identified.

• Notes

• Notes

• Is the problem due to change in equipment or substances?

  Select Equipment Substances

  • Equipment
  • Substances

• Equipment Issue?

  Select Configuration Maintenance Commissioning Control of Use Decommissioning

  • Configuration
  • Maintenance
  • Commissioning
  • Control of Use
  • Decommissioning

• Issue was previously identified.

• Notes

• Substances Issue?

  Select Supply Storage Emergency Arrangements Disposal

  • Supply
  • Storage
  • Emergency Arrangements
  • Disposal

• Issue was previously identified.

• Notes

• Is the problem due to change in equipment or substances?

  Select Equipment Substances

  • Equipment
  • Substances

• Equipment Issue?

  Select Configuration Maintenance Commissioning Control of Use Decommissioning

  • Configuration
  • Maintenance
  • Commissioning
  • Control of Use
  • Decommissioning

• Issue was previously identified.

• Notes

• Substances Issue?

  Select Supply Storage Emergency Arrangements Disposal

  • Supply
  • Storage
  • Emergency Arrangements
  • Disposal

• Issue was previously identified.

• Notes

Procedures

• Were the procedures a factor in the Incident?

  Yes, they were a factor.

  No, not a factor.

• Were the procedures adequate?

  Adequate but not used.

  No longer adequate

  Never adequate

• Was the employee suitable?

  Employee was suitable.

  Employee is no longer suitable.

  Employee was never suitable.

• Why was the employee no longer suitable?

  Select Resulting from a change in the worker. Resulting from a change in the task. Resulting from a change in the environment.

  • Resulting from a change in the worker.
  • Resulting from a change in the task.
  • Resulting from a change in the environment.

• Issue was previously identified.

• Notes

• Why was the employee engaged in a task for which they were unsuitable?

• Issue was previously identified.

• Notes

• Was the employee competent?

  Employee was competent.

  Employee was no longer competent.

  Employee was never competent.

• Why was the employee no longer competent?

  Resulting from a change in the worker.

  Resulting from a change in the task.

  Resulting from a change in the environment.

• Issue was previously identified.

• Notes

• Why was the employee engaged in a task for which they were not competent?

• Issue was previously identified.

• Notes

• Was the incident the result of intentional or unintentional circumstances.

  Unintentional

  Intentional

• Were they following accepted procedure, mistaken about the procedure, violating the procedure?

  Standard Behaviour

  MIstaken understanding

  Violation

• Issue was previously identified.

• Notes

• Was the incident the result of a lapse or a trip?

  Lapse

  Slip

• Cause?

  Select Distracted? Unfit?

  • Distracted?
  • Unfit?

• Issue was previously identified.

• Cause?

  Select Ergonomics? Housekeeping? Hazard Controls?

  • Ergonomics?
  • Housekeeping?
  • Hazard Controls?

• Issue was previously identified.

• Notes

• What change affected the adequacy of the procedure?

  Select Change in the process. Change in the standard.

  • Change in the process.
  • Change in the standard.

• Up-to date information available?

  Up-to-date instructions aren't available.

  Up-to -date instructions are available but aren't implemented.

• Up-to date information available?

  Up-to-date standards weren't available.

  Up-to-date standards were available but not implemented.

• Issue was previously identified.

• Notes

• In what way is the procedure inadequate?

  Select Process information was inadequate. Standard information was inadequate.

  • Process information was inadequate.
  • Standard information was inadequate.

• Up-to date information available?

  Up-to-date instructions aren't available.

  Up-to -date instructions are available but aren't implemented.

• Up-to date information available?

  Up-to-date standards weren't available.

  Up-to-date standards were available but not implemented.

• Issue was previously identified.

• Notes

Short-term Corrective Actions

Action

• Action to be taken:

• Responsible Party:

  Select Murray Brost Ross Brice Ivo Nevesely Alex Nguyen Greg Penkala Billy Ambrose Colin Thalheimer John Freeman Peter Smith Jan Ng Bel Katoch Kevin Titus Brett Davidson

  • Murray Brost
  • Ross Brice
  • Ivo Nevesely
  • Alex Nguyen
  • Greg Penkala
  • Billy Ambrose
  • Colin Thalheimer
  • John Freeman
  • Peter Smith
  • Jan Ng
  • Bel Katoch
  • Kevin Titus
  • Brett Davidson

• Projected Completion Date:

  Date

• Actual Completion Date:

  Date

Long-term corrective actions

Action

• Action to be taken:

• Responsible Party:

  Select Murray Brost Ross Brice Ivo Nevesely Alex Nguyen Greg Penkala Billy Ambrose Colin Thalheimer John Freeman Peter Smith Jan Ng Bel Katoch Kevin Titus Brett Davidson

  • Murray Brost
  • Ross Brice
  • Ivo Nevesely
  • Alex Nguyen
  • Greg Penkala
  • Billy Ambrose
  • Colin Thalheimer
  • John Freeman
  • Peter Smith
  • Jan Ng
  • Bel Katoch
  • Kevin Titus
  • Brett Davidson

• Projected Completion Date:

  Date

• Actual Completion Date:

  Date