MONITORING SHEET

PLANNED INSPECTION
DEPARTMENT: MONTH:
AREAS WHAT WHY ACTION
INSPECTION Opportunity for
NO DATE SECTION REASON REMEDIAL ACTION (TO FIX REASON) DATE COMP RESPONSIBLE
AREA Improvement

TASK OBSERVATIONS
WHAT WHY ACTION
PERSON Opportunity for RESPONSIBLE AND
NO DATE TASK COVERED REASON REMEDIAL ACTION to fix REASON DATE
OBSERVED Improvement OBSERVED SIGNATURE

SITE INSTRUCTION
AREAS WHO ACTION

NO DATE SECTION ISSUED BY Opportunity for Improvement REMIDIAL ACTION (TO FIX REASON) RESPONSIBLE PERSON DATE COMPLETE

INCIDENTS / DAMAGES
WHAT WHY ACTION
DATE AREA NATURE OF DAMAGE / INCIDENT COST CAUSE REMEDIAL ACTION

INJURIES
WHAT WHY ACTION
DATE NAME COY NO. AREA NATURE OF INJURY REASON REMEDIAL ACTION

REVISION No. 4 REVISION DATE: 10 01 23