Health and Safety Indicator Log
Log and monitor workplace health and safety indicators to ensure a safe environment.
Date and Time of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident or Observation
*
Name of Person Reporting
*
First Name
Last Name
Contact Email
*
example@example.com
Type of Indicator
*
Incident
Near Miss
Hazard Observation
Unsafe Act
Other
Description of Incident, Hazard, or Observation
*
Severity Level
*
Minor
Moderate
Major
Critical
Immediate Actions Taken
*
Is Further Follow-Up Required?
*
Yes
No
Status of Resolution
*
Please Select
Open
In Progress
Closed
Upload Supporting Photos or Documents (if any)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
How would you rate the overall safety performance at this location?
1
2
3
4
5
Submit Log
Should be Empty: