Electrical Trip Hazard Report Form
Report electrical trip hazards quickly and completely. Please provide as much detail as possible.
Location of the hazard
*
Specific area or room
What caused the trip hazard?
*
Please Select
Exposed wiring
Loose cables
Damaged floor covers
Obstructed walkways
Wet or slippery surface
Other
Describe the condition observed
*
Date and time noticed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Your full name
*
First Name
Last Name
Were any injuries sustained?
*
No
Yes
Immediate actions taken
Upload a supporting photo (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional notes or comments
Submit Report
Should be Empty: