REPORT OF SAFETY HAZARD
|
EMPLOYEE’S NAME: (Optional)
_______________________________________________ |
DEPARTMENT: __________________________________ DATE REPORTED: _______________________________ |
|
HAZARD REPORTED TO: ________________________________________________ |
|
DEPARTMENT SAFETY REPRESENTATIVE: ______________________________ |
|
DESCRIPTION OF HAZARD: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ |
|
ACTIONS TAKEN TO ABATE HAZARD: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ |
Date Hazard Abated:______________________
Signed:_________________________________
(Supervisor)