Synergo LLC
www.teamsynergo.com-503.746.6646
15995 SW 74th Ave STE 200, Tigard Oregon 97224
STAFF SAFETY REPORT
Date:
-
Month
-
Day
Year
Date
Name (optional):
SOURCE (please check one)
Pre-Use Inspection
Periodic Inspection
Safety Committee
Observation
What is the hazard's location?
Follow up Required?
Yes
No
DESCRIPTION OF HAZARD/POTENTIAL HAZARD
RECOMMENDATION FOR CORRECTION
FOLLOW-UP ACTION REQUIRED
Give this form to manager
Person responsible for follow-up:
Date follow-up completed:
-
Month
-
Day
Year
Date
Issue added to pre-use checklist?
Yes
No
Originator notified?
Yes
No
Date notified:
-
Month
-
Day
Year
Date
Document created by Synergo
15995 SW 74th Ave Suite 200 Tigard, Oregon 97224
www.teamsynergo.com (503) 746-6646 phone
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