Unsafe Condition Report Form
Use this form to report any unsafe conditions observed at your workplace or site. Please provide as much detail as possible to ensure a timely and effective response.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Location of Unsafe Condition (Site/Area/Department)
*
Date and Time Observed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Hazard
*
Slips, Trips, and Falls
Electrical Hazard
Fire Hazard
Chemical Exposure
Ergonomic Hazard
Equipment/Machinery Hazard
Blocked Emergency Exit
Poor Housekeeping
Other
Detailed Description of Unsafe Condition
*
Is there an immediate danger or risk of injury?
*
Yes, immediate danger
No immediate danger
Uncertain
Is the area currently accessible?
*
Yes, area is accessible
No, area is restricted/closed
Not sure
Has anyone been notified about this condition?
*
Yes, supervisor/manager notified
Yes, safety team notified
No, not yet
Other (please specify)
Suggested Corrective Action
Upload Photo or File Evidence (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Report
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