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Safety and Health Hazard Reporting Form

The data collected through this form will be used to help locate, evaluate, and resolve reported workplace safety hazards. This form is intended to be an anonymous method for reporting hazards. Raw data from reports will not be shared with persons outside of the Environmental Health, Risk Management, Safety and Loss Control Department. However, processed information about the specific hazard will be provided to campus management staff who have responsibilities for investigation and correction of hazards. No effort will be made to identify or link hazard reports to those who may make reports.


  1. Date:
    Time:
    Location:



  2. Yes
    No