UESI Report of Counseling v.1

• Audit Title

• Date of Observation

  Date
• Location
  Address

• Prepared by

• Position

  Select President Vice President Project Manager Safety Manager Shop Manager Manager Supervisor Co-Worker Oversight Client Employee

  • President
  • Vice President
  • Project Manager
  • Safety Manager
  • Shop Manager
  • Manager
  • Supervisor
  • Co-Worker
  • Oversight
  • Client
  • Employee

• Name of employee:

• Worker Status:

  Select Full Time Part Time Sub Contractor Other

  • Full Time
  • Part Time
  • Sub Contractor
  • Other

• Number of occurrence:

  Select 1st Documented 2nd Documented 3rd Documented 4th Documented Unknown Multiple

  • 1st Documented
  • 2nd Documented
  • 3rd Documented
  • 4th Documented
  • Unknown
  • Multiple

• Category of event:

  Select Unsafe Act Good Practice Injury Potential for injury Damage to equipment Near Miss Failure to follow instructions Safety Violation Insubordination Ignoring company policy Hostility / Aggression toward other employees

  • Unsafe Act
  • Good Practice
  • Injury
  • Potential for injury
  • Damage to equipment
  • Near Miss
  • Failure to follow instructions
  • Safety Violation
  • Insubordination
  • Ignoring company policy
  • Hostility / Aggression toward other employees

• Sub-Category:

  Select PPE Violation Hardhat Gloves Eye Protection Ear Protection Safety Shoes PFD Protective Clothing Fall Protection Removal of Safety Devices Other

  • PPE Violation
  • Hardhat
  • Gloves
  • Eye Protection
  • Ear Protection
  • Safety Shoes
  • PFD
  • Protective Clothing
  • Fall Protection
  • Removal of Safety Devices
  • Other

• Name of immediate supervisor:

Observation Detail

• Description of event / What happened:

• Corrective action:

  Select Closed / No Action Required Open / Follow-up Action Reccommended Coached / Corrected Removed From Jobsite

  • Closed / No Action Required
  • Open / Follow-up Action Reccommended
  • Coached / Corrected
  • Removed From Jobsite

• Add media

  Media

• Witnesses to the event:

• Further corrective action required, or taken:

Signature

• Person Signing:

  Select Signed By Employee Employee Refused to Sign Signed by Witness Co Counsel Signature Observer Signature Counselor Signature

  • Signed By Employee
  • Employee Refused to Sign
  • Signed by Witness
  • Co Counsel Signature
  • Observer Signature
  • Counselor Signature

• Name and Signature

  Sign