Corrective Action Form - Tasmania

Freemasons’ Homes of Southern Tasmania

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CORRECTIVE ACTION FORM

Log No:

7 Ballawinne Road

Phone: 6282 5200

(ONE ITEM PER FORM ONLY)

Lindisfarne Tas 7015

Fax:

6282 5266

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Risk Rating*:

REQUEST FOR ACTION

(COMPLETE THIS SECTION ONLY)

Date:……………………

Time:…………………

Wing/Area:…………..……………

Room No. or Location:……………..………..……….……

Give precise details: ...............................................................................................................................................................................................................

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Safety Hazard to Residents/Staff?

:

Yes

No

Reporter’s Name: .......................................

(please tick pertinent box)

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Signature ....................................................

Supervisors comments: ...............................................................................................................................

Supervisor’s Initials: ....................................

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Manager’s Instructions: ..................................................................................................................................

Manager’s Signature ..................................

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ACTION TAKEN

(BY FREEMASONS HOMES STAFF MEMBER AUTHORISED TO RESOLVE OR REFER THIS ISSUE)

Date:……………………….. Time:

…………………

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Department: ...............................................

Costing where appropriate: .........................................................................................................................

Print name: .................................................

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Signature:

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AS A FREEMASONS HOMES CONTRACTOR/SPECIALIST PROVIDER OR THEIR AGENT. THIS SECTION

IS TO BE COMPLETED IN ITS ENTIRETY

(What was performed to resolve/rectify the issue?).

Date: ……………………….. Time:

…………………

Give relevant details: ..............................................................................................................................................................................................................

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Name of Service .........................................

Where delays in resolving the issue are expected, i.e. parts, supply etc. an E.T.A. or completion time to be nominated: ........................................................

Job Start Time: ………………………………..

Job Completion Time: ………………………………………Signature: ................................................................

*

Rating 1 – real or potential immediate risk to residents or other personnel, or the Home’s infrastructure:

Rating 2 – foreseeable serious risk to persons or infrastructure in the medium term.

Requires immediate remedial action

Remedy within 1 calendar day.

Rating 3 – low risk but real or potential discomfort or inconvenience to residents or staff.

Rating 4 – little or no risk to residents or staff. Low risk to infrastructure.

.

Remedy within 2 working days

Remedy within 5 working days, or as soon as practicable

FMH Corrective Action

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