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Location: Check Date:
Inspection Performed by:
Frequency: ☐ Daily ☐ Weekly ☐ Monthly ☐ Other: ___________
This checklist is designed to ensure that all applicable safety control measures are implemented and maintained in accordance
with the identified risks and operational requirements. It supports compliance with safety standards and promotes a safe
working environment.
A. General Area Comment
B. Electrical Safety
Rate the Potential Severity of the incident Low Moderate High Severe
(First Treatment) (Medical Treatment) (ambulance or ( Death or severe)
other emergency
Employee Reporting: ------------------ Job Title : ---------------------- Signature:------------------- Date:--------------------------
Next action forward this form with the section A to the immediately supervisor. If you cannot locate him pass to the local manager for forwarding to the
immediately supervisor
Section B: to be completed by supervisor immediately
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Investigation of Incident
Incident Causes and Significant Contributing Factors (Check all that apply)
Basic Root Cause(s) Cause Group (People Related) Cause Group (Work Environment Related)
Environmental conditions (e.g smoke dust…)
Abuse or misuse
Environment
1 Safe operating procedures not followed Equipment or materials
Fire and explosion hazard
Equipment in workplace not communicated
Change equipment not used
Available Inadequate or improper personal protective equipment
Supervision Improper loading / lifting Noise exposure
Engineering (includes design) Improper placement / position for task
Maintenance Poor / inadequate housekeeping
Tools
Personal protective equipment not used Spill / Exposure 3
Safety devices not activated Unsafe work conditions
Training / Orientation Using equipment improperly Work Place design/ergonomics
Work procedures/process/standards
Full Investigate: ---------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------
Immediate Supervisor: ------------------- Job Title: --------------------------- Signature: ------------------- Date:-----------------------
Next action forward this form to the safety officer
Section C: to be addressed within 24 hours from notification
Recommendation to Prevent Reoccurrence of this incident
Did the incident have a risk assessment before ? Yes No if yes , Link to
NCR#:------------------
If No, Please Fill the table below
Follow Preventive Action Person Responsible EST.Completion Date
Check when done
Name : ------------------- Job Title: --------------------------- Signature:---------------------- Date: -------------------------
Next action copy of this report must be provided to the person making the report .The original must be retained by OHS department
☐ copy provided to person making report Date: ---------------------------
Approved by:
Name:
Position: OHS Supervisor
Signature:
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Date:
Document: JB/OHS/F003/V1 Issue no: 1 Page no: Page 3 of 2
