Unsafe Act/ Condition report

1. In Which Job:

2. While doing What:

3. What could happen:

4. What is unsafe:

5. Sketch:

6. Entropy Incident Reported Number : INCID-

7. Include in Kaizen contest: Yes/No

8. Suggested Kaizen to prevent Unsafe act/ Condition:

9. Kaizen will be completed by:

Name of Employees :

Expected date for completion :

10. Submitted by:

(Name, Department and Clock No.)
11. Date and signature: