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MILLWRIGHT SAFESTART - KAUKAUNA
NAME:
PHONE:
ADDRESS:
CITY/STATE/ZIP:
EMAIL:
Did you have an incident today?
CONTRACTOR:
Check which state, critical errors were factors.
WORK MO/YR:
Check which CERTs may have prevented it.
DAY
RELATED
WORK
GENERAL
ERECTION
MACHINERY
ERECTION
MAINTENANCE
WELDING
TOTAL
HOURS
SAFESTART TRAINING
INCIDENTS
IF "YES" SELECT INCIDENT TYPE
STATES
CRITICAL
ERRORS
CERTS
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Yes
No
No
Yes
None
Property Damage
Near Miss
First Aid
Recordable
Lost Time
R
FR
FA
C
E
L
M
B
S
A
L
W
Totals
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