Initial Date: January 2015

Revision Date: January 2017 Safety, Health and Environment

Standards
Revision No: 01
Document No:

SAFETY, HEALTH & ENVIRONMENT REPRESENTATIVE MONTHLY INSPECTION REPORT

Health & Safety Representative: Area:
Inspection Date: Section Inspected:
In Order = OK Not In Order = NO Broken or Defective = DEF Not Applicable = N/A

Required Action: Responsibility for Required

Inspection Criteria: Observation / Findings: Date Completed:
(To Be Completed by the Supervisor) Action:
1. Premises & Housekeeping
1.1 Buildings & Floors
1.2 Lighting
1.3 Ventilation
1.4 Plant Hygiene: Kitchens, Tea Room &
Toilets Clean
1.5 Walkways & Storage
1.6 Stacking & Storage
1.7 Storage, Salvage Yard Tidy / Locked
1.8 Scrap Removal System
1.9 Colour Coding Evident
2. Mechanical, Electrical & Personal Safeguarding
2.1 Machines adequately Guarded
2.2 Labelling of Switches / valves
2.3 Ladders, Handrails & Scaffolding
2.4 Lifting Equipment (Condition & Use)
2.5 Vehicles – Prestart Checklist &
Condition
2.6 Portable Electrical Equipment &
Record
2.7 Gas Cutting Equipment & Record
Initial Date: January 2015
Revision Date: January 2017 Safety, Health and Environment
Standards
Revision No: 01
Document No:

2.8 Electrical Installations

2.9 Hand Tools & Record
2.10 Ergonomics
2.11 PPE Usage as per Standard
2.12 PPE Clothing Condition & Record
2.13 Notice / Symbolic Safety Signs
3. Fire Protection and Fire Prevention
3.1 Extinguishing Equipment & Record
3.2 Locations Marked, Floors Clean
3.3 Maintenance of Equipment
3.4 Storage Flammable / Explosives
3.5 Alarm System
3.6 Emergency Planning
4. Environmental
4.1 Incidents Reported (e.g. oil leaks,
spillage, emmisions)
4.2 Water Leaks & Spillages
4.3 Oil Trap, Channels Clean &
Functional
4.4 Storage containers / skips free from
leaks and corrosion
4.5 Waste areas and container clearly
labelled
4.6 Water or gas pipelines and valves in
good state or repair
4.7 Hazardous and domestic waste sorted
and in correct bins
Initial Date: January 2015
Revision Date: January 2017 Safety, Health and Environment
Standards
Revision No: 01
Document No:

4.8 Storage areas of hazardous waste

adequately bunded
4.9 Pollution from hazardous / domestic
waste (solid / liquid)
4.10 Pollution – air, water / soil
5. Radiation
5.1 Controlled areas demarcated
5.2 Warning signs displayed
6. General (Any item not listed)

Health & Safety Representative Supervisor Chairperson – Departmental SHE Forum

As the legally appointed Health & Safety Representative As the legally appointed Supervisor for the area where As the Chairperson of the SHE Forum for this section,
for the abovementioned section, I have conducted my this inspection took place, I agree that the listed I have examined the findings of this report and
monthly inspection and this report represent an accurate observations are SHE hazards and that the steps as confirm that, unless otherwise indicated, they will be
and true reflection of my findings. indicated above have been / will be taken to correct the addressed and implemented.
hazard.
Name: Name: Name:
Emply Nr: Emply Nr: Emply Nr:
Signature: Signature: Signature:
Date: Date: Date: