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Safety Group Name

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Firm Name page Page
WSIB Firm No.

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WSIB Account No. Date (dd/mm/yyyy)

Completed By Telephone
Safety Groups Action Plan
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Element Current Status
(from Workplace Completion Date
(Choose from Achievement List) Objectives for Year Responsibility (dd/mm/yyyy)
Assessment)
Leadership: Set Standard
Communicated
Trained
Evaluated
Check if Group Element: Acknowledged Success

Organization or Hazard Recognition Set Standard

& Assessment: Communicated
Trained
Evaluated
Check if Group Element: Acknowledged Success

Other: Set Standard

Communicated
Trained
Evaluated
Check if Group Element: Acknowledged Success
Other: Set Standard
Communicated
Trained
Evaluated
Check if Group Element: Acknowledged Success

Other: Set Standard

Communicated
Trained
Evaluated
Check if Group Element: help/tips
Acknowledged Success
H
Signature: Senior Management Joint Health & Safety Committee Chair (Optional)

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Please print form & sign before returning. Please print form & sign before returning.
3168A (12/07)
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