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    OHS 5.3.1aPreventiveandCorrectiveActionForm

    Uploaded by

    fcleong69
    This form is used to document accidents, incidents, near misses, audit findings, inspections, work refusals, and identified hazards. The initiator provides details of the issue including description and severity. Immediate actions are taken to prevent recurrence, the root cause is identified using a "5 Whys" method, and contributing factors are analyzed. A corrective action plan is made with responsibilities, timeline, and verification of effectiveness. Signatures are required from the initiator, implementer, and safety committee member when hazards are reported.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    OHS 5.3.1aPreventiveandCorrectiveActionForm

    Uploaded by

    fcleong69
    143 views1 page
    This form is used to document accidents, incidents, near misses, audit findings, inspections, work refusals, and identified hazards. The initiator provides details of the issue including description and severity. Immediate actions are taken to prevent recurrence, the root cause is identified using a "5 Whys" method, and contributing factors are analyzed. A corrective action plan is made with responsibilities, timeline, and verification of effectiveness. Signatures are required from the initiator, implementer, and safety committee member when hazards are reported.

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    HSE

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    This form is used to document accidents, incidents, near misses, audit findings, inspections, work refusals, and identified hazards. The initiator provides details of the issue including description and severity. Immediate actions are taken to prevent recurrence, the root cause is identified using a "5 Whys" method, and contributing factors are analyzed. A corrective action plan is made with responsibilities, timeline, and verification of effectiveness. Signatures are required from the initiator, implementer, and safety committee member when hazards are reported.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    143 views1 page

    OHS 5.3.1aPreventiveandCorrectiveActionForm

    Uploaded by

    fcleong69
    This form is used to document accidents, incidents, near misses, audit findings, inspections, work refusals, and identified hazards. The initiator provides details of the issue including description and severity. Immediate actions are taken to prevent recurrence, the root cause is identified using a "5 Whys" method, and contributing factors are analyzed. A corrective action plan is made with responsibilities, timeline, and verification of effectiveness. Signatures are required from the initiator, implementer, and safety committee member when hazards are reported.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Preventive and Corrective Action Form

    This form is to be completed for accidents, incidents/near-misses, audit findings, workplace inspection findings, work refusals, identified hazards, etc. Please forward the
    completed and signed form to the Office of Occupational Health & Safety.

    SECTION A: DESCRIPTION OF PROBLEM (To be completed by Initiator)


    Name:

    Date:

    How was the event discovered?


    Accident/incident investigation
    Audit
    Workplace inspection
    Work refusal
    Hazardous condition observed
    Other:
    Have you collected all the information to allow you to do an investigation as required (e.g. witness statements, photographs, training records)?
    YES
    NO
    Description of problem (if the description is described in the Accident/Incident Report, please attach to this
    form and make reference to it here):

    Non-conformance / hazard
    rating:
    Major
    Moderate
    Minor
    Opportunity for improvement

    SECTION B: IMMEDIATE ACTION, ROOT CAUSE AND ACTION PLAN (To be completed by Implementer, if different from the Initiator)

    Take immediate action. What immediate action was/should be taken to prevent recurrence (e.g. isolate hazard, remove hazard, lock out, post signage, restrict access, etc.)?

    Identify the root cause. (use the 5 Whys ask Why 5 times to identify the root cause, or other
    comparable method. Implementer must observe process visually. Also, use the checklist to identify
    contributing factors and provide additional details for each that apply).

    Date of First
    Response:

    Identify contributing factors.


    Lack of training
    Improper housekeeping/storage
    More than one operator/employee
    Lack of proper safety tool or device
    Hazardous personal attire
    Unsafe method or procedure
    Unsafe equipment/facilities/illumination
    Distracting, teasing, willful misconduct
    Improper machine operation
    Employee(s) of another company
    Failure to use PPE
    Other:
    Improper maintenance
    Identify the corrective/preventive action(s) which will permanently address the causes identified above. Identify if the action creates a new risk. If so, do not implement
    action and contact the OHS Manager. Identify who is the responsible party, due date, and completion date (e.g. instructions of persons involved, reassignment of persons,
    improved PPE, installation of guard or safety device, notify all department supervision, disciplinary action).
    Ne
    SECTION C: VERIFICATION***
    w
    (To be completed by Initiator (if different from Implementer),
    CSC member, or OHS Manager following completion of PCA)
    PCA
    Department(s)
    Due
    Ris
    Preventive/Corrective Action
    Responsible
    Party
    *
    Date
    #
    Affected
    Date
    k**
    Effectiveness of Action
    Date
    Complet
    (Y/
    Verified by
    Verified
    e
    N)

    * PCA number to be assigned by the Office of Occupational Health and Safety


    ** If a new risk is created by the PCA, do not implement the action and contact the Occupational Health & Safety Manager for alternative solutions.
    *** Following the completion of Section B and prior to the completion of Section C, the form should be signed by the initiator and the implementer and forwarded to the Office of Occupational Health & Safety.

    SECTION D: SIGNATURES
    Implementer Signature:

    Title:

    Date:

    Initiator Signature:

    Title:

    Date:

    CSC Member Signature (required when hazards are reported):

    Date:

    Attach additional sheets if necessary.


    OHS-5.3.1a Preventive and Corrective Action Form Rev: 10/22/07

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