HEALTH AND SAFETY ACTION PLAN FORM
Health and Safety Action Plan (Sample)
The fillable form is on page 2.
Identified Hazard Description of Training Types of Controls Needed Responsibility
Manual material handling
Proper Lifting and Carrying
Redesign of MMH procedures
including use of motorized
Reviewed and approved by:
C. Andre Date: November 1, 2011
(name and employer or designate)
(A) Hazard Category: Identify whether it is a Physical, Biological, Chemical, Ergonomic or Physiological hazard.
(B) Identified Hazard: Indicate the type of Physical, Biological, Chemical, or Ergonomic hazard. For instance, a slipping and tripping hazard, a hazard caused by
moving parts of machinery, fumes or violence – just to name a few.
(C) Description of Training: Indicate the type of training required to help eliminate if not reduce the frequency of exposure to this hazard.
(D) Types of Controls Needed: Indicate the type of controls needed to help eliminate if not reduce exposure to this hazard. For example, redesigning the
workstation if reasonable possible.
(E) Responsibility: Name of the individual who is responsible to arrange the training and ensure reasonable controls have been put in place to eliminate or
reduce the hazard. For example the health and safety coordinator.
(F) Target Completion Date: The intended date where potential actions should be completed.
(G) Completion Date: The date where potential actions are complete.