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
2 digit month, 2 digit day, 4 digit 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
Drag and drop files here
Choose a file
Cancel
of
Submit Report
Should be Empty: