ENVIRONMENT SAFETY & HEALTH SURVEILLANCE REPORT

SECTION 1: FINDINGS - To be completed by ESH Committee

Company:
ADMC
Department / Location: Date of Surveillance:
 New report  Re-issued report

Detailed findings:

_____________________________________ ____________________________
Signatures of ESH Committee Acknowledgement by ESH / TQEM
Date of report: Date:

SECTION 2: ACTION PLAN - To be completed by Department Manager / Unit Head / Process Owner
ROOT CAUSE:

Source of Document: ESH / Mar 2014

CORRECTION:
(Immediate action to rectify this non-compliance) Expected Date of Completion :

CORRECTIVE ACTION:
(Action to prevent recurrence of this / similar non-compliance) Expected Date of Completion :

Signature of Manager / Unit Head / Process Owner: Date:

SECTION 3: REVIEW & VERIFICATION - To be completed by ESH Committee

 Corrective action is not effective Report re-issued, (Date re-issued):

 Corrective action in progress and follow – up required Date to follow-up:

 Corrective action completed and effective

Evidence of corrective action:

Signature of ESH Committee: Date:

SECTION 4: REPORT CLOSE-OUT - To be completed by ESH / TQEM

 Report close-out
Signature of ESH: Date:

Source of Document: ESH / Mar 2014