WORKSITE INSPECTION FORM Date:_____________________________________ Location:__________________________________________________________________ Completed by: ___________________________________ OBSERVATIONS FOLLOW UP Hazard Repeat ACTION REPORTED DATE Severity Item HAZARD(S) OBSERVED DATE TAKEN ITEM # ACTION TO Completed BY WHOM (A,B,C) Yes No Hazard Severity: Control must be put in place before work, Control must be put in place within two days, Control must be put in “A” – “B” – “C” – place within one week.
WORKSITE INSPECTION FORM Date:_____________________________________ Location:__________________________________________________________________ Completed by: ___________________________________ OBSERVATIONS FOLLOW UP ITEM # HAZARD(S) OBSERVED Hazard Severity Repeat Item ACTION REPORTED TO DATE ACTION TAKEN BY WHOM DATE Completed (A,B,C) Yes No Hazard Severity: “A” – Control must be put in place before work, “B” – Control must be put in place within two days, “C” – Control must be put in place within one week.