UNSAFE CONDITION OR HAZARD

INTIMATION FORM
Location: Rubber Division: Rubber

I. Unsafe Condition or Hazard

Name: Selva Kumar JobTitle: Prod: Engineer
Location of Hazard: Rubber – Molding
Building: HIRA- RAKIA Floor: Room: ______________
Date and time the condition or hazard was observed:
March 13
Description of unsafe condition or hazard: Spray Painting Activity found on shop Floor

What changes would you recommend to correct the condition or hazard?

All painting activity done only in designated Painting room

Employee Signature: (optional) __________________________________________________________

Date : March 13

II. Management / Safety Committee Investigation

Name of person investigating unsafe condition or hazard:

Mr.Aby

Results of investigation (What was found? Was condition unsafe or a hazard?): (Attach additional
sheets if necessary.)
On March 13th approx. 10:30 spray painting activity fond at normal work area

Proposed action to be taken to correct hazard or unsafe condition:

Immediately stop the activity and reported to the PM

Signature of Investigating Party: _________________________________________________________

Date: ____________________________

Doc. No. HI – RAK – MRI – FOR – 031 – 17, Rev.0 21 November 2017 Page 1