SST045
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Site conducted
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Conducted on
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Prepared by
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Location
Information Required
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Unsafe Action/Condition Notification
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YELLOW CARD
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Yes / No
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RED CARD
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You have committed a serious breach of health, safety or environmental rules by putting yourself and other persons at risk. Conclusion is exclusion from site.
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Details (ADD Induction no)
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Name of operative who breached rules
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Sub-Contractor
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Trade
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Work Activity being conducted
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Location
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Time breach was observed
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Date breach was observed
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Unsafe Action/Condition Observed - State the HS&E practice that has been breached and why the notice is being issued. To be completed by the issuer.
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Date of last offence
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Repeat offence
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Corrective Action Taken to Prevent Recurrence
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Notice served by
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Name
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Job Title
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Signature
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Date
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Sub-Contractor Notice received | confirm that I understand why this notice has been issued and why action has been taken to rectify the non-conformance. I confirm that the corrective action has been undertaken.
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Sub Contractor Name
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Job Title
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Sub-Contractor
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Date
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Signature
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JCD Group Management Close out
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I confirm that the corrective action has been undertaken and checked as complete and sufficient.
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Name
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Job Title
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Signature
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Date
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Comments (if applicable)
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Distribution Lists: All JCD Group Project Managers, On-Site Management Team, Health and Safety Manager, On-Site and JCD Group Administrator
