Report Safety Concern or Incident

This form is for employee's who wish to report a safety concern or a incident that has happened to you or a fellow coworker.

Your Name

Optional, but recommended for assisting in investigations.

First Name

Last Name

Type of Report

Concern

Incident

If concern, what type?

Safety Hazard - are unsafe working conditions that that can cause injury, illness, and death. Biological Hazard - include exposure to harm or disease associated with working with people. Physical Hazard - can be any factors within the environment that can harm the body without necessarily touching it. Electrical Hazard - have a risk of injury or death from electric shock or poses as a fire risk. Ergonomic Hazard - occur when the type of work, body positions and working conditions put a strain on your body. Chemical Hazard - are present when a worker is exposed to any chemical preparation in the workplace in any form. Work Organization Hazard - are associated with workplace issues such as workload, lack of control, and/or respect.

Summarization of the Safety Concern or Incident

Name of person(s) committing concern or involved in incident?

Separate names with a comma ","

Additional information

Name of Witness(es)

Witness 1

Witness 2

Witness 3

Date and time of concern or incident?

Date

YYYY

Approximate Time