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PDCA Template for Action Planning

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Hazard Identification
Describe Hazard
Hazardous Condition
Unsafe Behavior
Possible Accident Types
Please specify
Risk probability
Risk severity
Recommended Corrective Action(s)
Engineering controls
Management controls
Personal Protective Equipment
Recommended System Improvement(s)
Specify recommended improvement(s)
Determination of Legal and other Requirements
Name of regulation/requirement
Reference #
Area of the organization it impacts
Interested parties
Document stipulating the requirement/compliance obligation
Responsible Person
Source of information (can be indicated in a hyperlink or description format)
Objective Planning
What is to be done?
Resources required (e.g., financial, human, equipment & infrastructure)
Responsible person
Target date of completion
Metrics for evaluation & indicators for monitoring
Priority Level
Approved by
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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