Facility Hazard Report Form
Report hazards observed in the facility accurately and promptly to ensure safety and compliance.
Your Full Name
*
First Name
Last Name
Department or Area
*
Contact Information (Phone or Email)
*
Date and Time Hazard Was Observed
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Exact Location of Hazard (e.g., Building, Floor, Room)
*
Hazard Category
*
Please Select
Slip, Trip, or Fall
Electrical
Chemical
Fire
Mechanical
Ergonomic
Other
Describe the Hazard
*
Immediate Danger Level
*
Low
Moderate
High
Critical
Is the Hazard Currently Ongoing?
*
Yes
No
Immediate Action Already Taken (if any)
Upload Supporting Photo (if available)
Upload a File
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of
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