SAFETY OFFICE INSPECTION NOTICE

TO:

FROM:

Report completed and returned

24 HRS
WITHIN 5 DAYS
WITHIN 10 DAYS

BLDG NO

OCCUPANCY

ACTIVITY BASE

DATE AND HOUR OF INSPECTION

BRIEF DESCRIPTION OF SAFETY HAZARD(S)

ACTIONS REQUIRED TO CORRECT SAFETY HAZARD(S)

DATE OF REPORT

SIGNATURE OF SAFETY INSPECTOR

SIGNATURE OF SAFETY REP/ADVISOR

TO:

FROM:

CORRECTIVE ACTION COMPLETE

(Explain if 'NO' is checked)
YES

REMARKS:

NO