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Hazard Inspection

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Form
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Hazard INSPECTION Reporting Form
DATE: TIME: LOCATION:

Description of hazard, near miss, unsafe act or condition observed:

TYPE: RISK LEVEL: RESPONSIBLE:

Possible Impacts:

Immediate Actions:

team names & Signatures:

Departmental Supervisor: Date Completed:

Plant Manager:
Safety Coordinator: Cost of Action:
[H&S Rep] Savings:

auditee notes:

department head sign.

M.R. Notes:

system representative sign.