Fillable Printable Hazard Report Template
Fillable Printable Hazard Report Template
Hazard Report Template
Page1
Department o f PublicSafety
Workplace Safety& Health DivisionSafetyHazard Reporting Form
HAZARD REPORTING
FORM
OwensCommunityCollege is committedtomaintainingasafe workenvironment. A safe work environment
is one which is freefromaccidents, injuriesand work-relatedillnesses. All employeesmust work togetherto
createandmaintain a safe environment forall employees, studentsandvisitors. OwensCommunity C ollege is
committedtostrict complianceofall Federal, StateandLocal Lawsconcerning workerhealth and safety.
OwensStateCommunityCollege employeesmayuse this formtoreportsafety issuestothe Departmentof
Public Safety, Workplace Safety& Health Division.TheSafety Departmentwill investigate the safety
issue/complainttodeterminewhatactionneedstobetaken.This formcanbesubmittedanonymously.
Employeesare advisedthatit is illegalforanemployertotake anyactionagainst anemployee in reprisal for
exercisingtheir rightsto reportsafety issues.
Date:
Time:
Employee’s
Name:
(Optional)
Department:
(Optional)
Phone
#
and/or
Email:
(Optional)
Describetheunsafe conditionor practice:
Location:
_
(Building, Floor, Room #, Department, etc.)
Hasthis matterbeenreportedtoyoursupervisor?YesNo
Do you wish to be notifiedof actiontaken:YesNo(If yes, please make sure contact information is available).
(Send completedform totheDepartmentof Public safety, Workplace Safety & HealthDivision.)
DPS Use Only:
Corrective ActionTaken:
Date:
Time:
By:
Subject: Safety Hazard Reporting Form Effective Date: January 2012
Procedure: S.2.ARevised: New
