RAPPORT DE VISITE DE CHANTIER

À LA SUITE D’UNE INSPECTION

Édition mars 2020

CCQ CNESST
Date de la visite de l’inspecteur sur le chantier : __________________________________________________________
Identification de l’inspecteur : _________________________________________________________________________
Identification du chantier : ____________________________________________________________________________
Donneur d’ouvrage : _________________________________________________________________________________
Maître d’œuvre : ____________________________________________________________________________________
Durée de l’inspection (heure d’arrivée et de départ) : _________________________________________________

Raison de la visite : _________________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

Identité des personnes rencontrées par l’inspecteur sur le chantier et les informations échangées

Nom : _______________________________________ Informations échangées - questions et réponses :

Coordonnées : ________________________________
____________________________________________
Tél. / Cellulaire : ______________________________
Déposition

Nom : _______________________________________ Informations échangées - questions et réponses :

Coordonnées : ________________________________
____________________________________________
Tél. / Cellulaire : ______________________________
Déposition

Nom : _______________________________________ Informations échangées - questions et réponses :

Coordonnées : ________________________________
____________________________________________
Tél. / Cellulaire : ______________________________
Déposition

Voir annexe — si nécessaire

L’infraction reprochée et la personne avisée de celle-ci :
__________________________________________________________________________________________
__________________________________________________________________________________________

Photos :
Par l’inspecteur :

Par le contremaître :

Description des faits et explications de la situation :

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Témoins
Témoins

Nom : _______________________________________ Informations échangées - questions et réponses :

Coordonnées : ________________________________
____________________________________________
Tél. / Cellulaire : ______________________________
Déposition

Nom : _______________________________________ Informations échangées - questions et réponses :

Coordonnées : ________________________________
____________________________________________
Tél. / Cellulaire : ______________________________
Déposition

Fait à  : ____________ le _______________________

Nom : _______________________________________
Fonction : ____________________________________

____________________________________________
Signature
Déposition

Nom : _____________________________________________________________________________________________
Coordonnées : ______________________________________________________________________________________
Tél. / Cellulaire : ____________________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

En foi de quoi, j’ai signé à : _____________________________________ En date du ____________________

Nom : _____________________________________________________________________________________

____________________________
Signature
Déposition

Nom : _____________________________________________________________________________________________
Coordonnées : ______________________________________________________________________________________
Tél. / Cellulaire : ____________________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

En foi de quoi, j’ai signé à : _____________________________________ En date du ____________________

Nom : _____________________________________________________________________________________

____________________________
Signature

Déposition

Nom : _____________________________________________________________________________________________
Coordonnées : ______________________________________________________________________________________
Tél. / Cellulaire : ____________________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

En foi de quoi, j’ai signé à : _____________________________________ En date du ____________________

Nom : _____________________________________________________________________________________

____________________________
Signature