Hazard Report Form
Use this form to report any hazards, unsafe conditions, or potential risks in the workplace. Your report helps ensure a safe and healthy environment for everyone.
Reporter Information
Name
First Name
Last Name
Department
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Hazard Details
Date of Observation
-
Month
-
Day
Year
Date
Location of Hazard
Type of Hazard
Please Select
Physical Hazard
Chemical Hazard
Biological Hazard
Electrical Hazard
Fire Hazard
Ergonomic Hazard
Other
Description of Hazard
Describe the hazard
What caused the hazard?
Who or what is at risk?
Who or what is at risk?
Severity Level
Please Select
Low
Medium
High
Critical
Likelihood of Occurrence
Please Select
Rare
Possible
Likely
Very Likely
Immediate Action Taken
Was any action taken?
Yes
No
If yes, describe actions taken
Supporting Evidence
Upload Photos or Files
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Follow-Up
Assigned To
Action Required
Status
Please Select
Open
In Progress
Resolved
Closed
Resolution Notes
Final Section
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: