Fillable WORKPLACE EXAM RECORD [Requirements Only] (Mine Safety and Health Administration)

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WORKPLACE EXAM RECORD [Requirements Only] (Mine Safety and Health Administration)

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WORKPLACE EXAM RECORD [Requirements Only]
Location*:
Date:
Shift:**
Competent person(s):***
WORKING AREA(S) EXAMINED:
Adverse Conditions
Date Corrected
*”Location” is meant to indicate the overall site—this could be “Mine” or “Plant” or “Unit,” as appropriate.
**The rule only requires that the date of the exam be noted. However, because the rule also requires that an exam be
performed for each shift, unless the shift is indicated it would be difficult to determine which shift the examination
covered.
***The competent person who performed the examination must be identified, but no signature is required.
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WORKPLACE EXAM RECORD Requirements Only (Mine Safety and Health Administration)

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Completed 19 July 2020

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