Fillable PREVENTATIVE ACTION PLAN (City of Stephenville)

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PREVENTATIVE ACTION PLAN (City of Stephenville)

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BROWSE CITY OF STEPHENVILLE (TX) FORMS

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If no action is planned, state why:
PREVENTATIVE ACTION PLAN
The Preventative Action Plus is intended to assist Departments in delivering and assigning specific measures to prevent
recurrence of similar accidents. One or more of the following may develop the Plan:
Immediate supervisor of injured employee
Other management personnel within the same division
Operations Manager/Safety Coordinator
The completed Preventive Action Plan must be submitted to Human Resources no later than fifteen (15) days from
injury notification.
Review and mark all realistic areas for Preventative Action (by Management) as well as Action (by Worker) to prevent
recurrence.
Based on the preventative action list above, the Supervisor’s investigation of the accident, and any ideas
received from Department or Safety personnel develop a specific task that can prevent recurrence of similar accidents in
the future. (Attach sheet if necessary)
Task #1
Assigned to:
Assignment Date:
Task #2
Assigned to:
Assignment Date:
Preventative Action Plan submitted by:
Title: Date Submitted:
Appendix E
Form 33
TRAIN OR COUNSEL WORKERS TO:
Follow established work procedures, Safe practices
Follow training program instructions
Wear required personal protective equipment
Wear required clothing
Use guards, safety devices properly
Operate tools, equipment, machinery properly
Secure, shut off, disconnect systems
Stop unauthorized work, activity
Stop recklessness, inattentiveness
Stop horseplay with others
Recognize and report hazards
Use better judgment, increase awareness
IMPROVE OR MODIFY:
Work procedures, Safe work place
Job hazard analysis
Training, orientation
Personal protective equipment
Tools, equipment, machinery
Guarding, safety devices
Facilities, lighting, ventilation
Maintenance
Housekeeping
Level of supervision
Level of supervision
Working conditions-hours
Page 251 of 254
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PREVENTATIVE ACTION PLAN (City of Stephenville)

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Completed 3 March 2021

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