Company Name
Health, Safety & Environment
UNSAFE ACT (UA)
OBSERVATION REPORT
ISO 45001:2018 Occupational Health & Safety
Doc No:LI-HSE-UA-001
Rev:01
Date:________
UNSAFE ACT OBSERVATION REPORT
ISO 45001:2018 | Clause 8.1 – Operational Planning and Control
UA Report No. Date Observed Time
Project / Site Location / Area
Observed By
Department
# Name Employee ID Designation Contractor / Staff
PERSONAL BEHAVIOUR
USE OF EQUIPMENT / TOOLS
PROCEDURE & COMPLIANCE
Other (specify here)
LIKELIHOOD
SEVERITY
RISK RATING
IMMEDIATE ACTION TAKEN?
Describe what was observed (who, what, where, when, how)
Potential consequence if not corrected
# Action Required Responsible Person Target Date Status
SECTION 7 — ACKNOWLEDGEMENT & SIGN-OFF
REPORTED BY REVIEWED BY (SUPERVISOR) CLOSED BY (HSE / MANAGER)
Name:
Sign:
Date:
Name:
Sign:
Date:
Name:
Sign:
Date:
This report must be submitted to the HSE Officer within 24 hours of observation. Retain copy on project file.
LI-HSE-UA-001 | ISO 45001:2018 CONFIDENTIAL – INTERNAL USE ONLY