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WSIB Account No. (dd-mm-yyyy)
Date (dd/mm/yyyy)

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Action Plan Progress
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Has the element Have you

Element (from Has a Has the Has applicable been evaluated or acknowledged
Achievement List) written standard standard been training been an evaluation plan success & made Comments
been set? communicated? completed? developed? improvements?

Leadership:

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Organization or
Hazard Recognition
and Assessment:

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Other:

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Other:

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Other:

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3166A (12/07) print

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