Health Check Operations Report Form
Document routine health check operations and outcomes.
Who is submitting this report?
*
First Name
Last Name
Date and time of health check operation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Area or team covered
*
Type of health check conducted
*
Please Select
Routine Inspection
Equipment Check
Safety Audit
Environmental Assessment
Other
Number of people checked
*
General outcome
*
All Clear
Minor Issues
Major Issues
Other
Issues observed (if any)
Actions taken
Next follow-up date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional notes
Submit Report
Should be Empty: