U SEE U ACT U SEE U ACT

Reporter Name/Nama Pelapor: Reporter Name/Nama Pelapor:

Area/Tempat Kejadian: Area/Tempat Kejadian:
Date/Tarikh: Date/Tarikh:
Time/Waktu: Time/Waktu:

Observation Category (choose one)/ Kategori Observation Category (choose one)/ Kategori
Pemerhation (pilih satu): Pemerhation (pilih satu):

Behavior/Kelakuan Behavior/Kelakuan
Slip & trip hazard/bahaya jatuh Slip & trip hazard/bahaya jatuh
Housekeeping /5s Housekeeping /5s
PPE/ Alat Perlindungan Diri PPE/ Alat Perlindungan Diri
Electrical/ Bahaya Elektrik Electrical/ Bahaya Elektrik
Manual Handling Manual Handling

Is it Near Miss/ Potential for Accident: Is it Near Miss/ Potential for Accident:

Report/maklumat (with sketch or picture if Report/maklumat (with sketch or picture if

necessary/dengan lakaran atau gambar jika necessary/dengan lakaran atau gambar jika
perlu): perlu):

Corrective action/Tindakan pembetulan: Corrective action/Tindakan pembetulan:

STATUS: □ OPEN □ ONGOING □ CLOSED STATUS: □ OPEN □ ONGOING □ CLOSED

Thank You Thank You

Terima Kasih Terima Kasih