5. Incident Reporting and Investigation 6. Emergency Response Inspection Checklist Date: Site: Department: Manager: Inspected by: Name:: Title: #: Name: #: Keys: for Verification: D=documentation O=observation I=interview/informal chat with employee for Status: C=complete PC=partially complete AR=attention required General Appearance of Area Reference (e.g., standard/Act/ Verification Risk regulations, etc.) Target/ Status Person(s) Item matrix Recommendation for correction completion (C, PC, Date of follow-up responsible score action and/or long term) based date AR) D O I on that reference lighting noise thermal conditions clutter Comments: Safety Reference (e.g., standard/Act/ Verification Risk regulations, etc.) Target/ Status Person(s) Item matrix Recommendation for correction completion (C, PC, Date of follow-up responsible score action and/or long term) based date AR) D O I on that reference three rights rules
5. Incident Reporting and Investigation 6. Emergency Response Inspection Checklist Date: Site: Department: Manager: Inspected by: Name:: Title: #: Name: #: Keys: for Verification: D=documentation O=observation I=interview/informal chat with employee for Status: C=complete PC=partially complete AR=attention required General Appearance of Area Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I lighting noise thermal conditions clutter Comments: Safety Item Risk matrix score Verification Reference (e.g., standard/Act/ regulations, etc.) Recommendation for correction action and/or long term) based on that reference Person(s) responsible Target/ completion date Status (C, PC, AR) Date of follow-up D O I three rights rules
OHC_Inspection_Checklist_Template_-_April_2015.docx