Target 5000 - S.I.F. Report

• Document No.

• Conducted on

  Date

• Prepared by

PART A - Team Member

• Please select Operations or Service

  Operations

  Service

• Area:

• Specific Location:

• TM's Involved (optional):

• Describe Near Miss/Hazard:

• Add media

  Media

• Immediate Actions Taken:

• Is there a Life Saving Behavior Challenge?

  Yes

  No

• Job PAUSE, ASSESS, contact your SUPERVISOR for support in removing the Life Saving Behavior Challenge

• Once you have completed PART A - Pass this report to your Supervisor

PART B - Supervisor - work with your team to identify possible solutions to prevent the Life Saving Behavior Challenges

• No 1 - Possible Actions:

• No 2 - Possible Actions:

• No 3 - Possible Actions:

• No 4 - Possible Actions:

• No 5 - Possible Actions:

• No 6 - Possible Actions:

• Life Saving Behavior Challenge Status:

• Please select the status

  ELIMINATED

  REMAINS

• Life Saving Behavior Challenge still exists, FURTHER ACTION required

• Life Saving Behavior Challenge no longer exists

• Add signature

  Sign