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. Please clearly describe the hazard, including whether this is a hazard because of an unsafe activity or an unsafe facility condition.

  2. Exactly when and where did you observe the hazard?

    Date:
    Time:
    Location:
  3. Other than reporting the hazard, have you taken any other action to attempt to address or resolve the hazard?

    Yes

    No

    If yes, please provide a detailed description of the actions you have taken along with the result of your actions. NOTE: Information from your response to this question will not be shared with others -- it is important for EHS staff to be aware of any attempts to resolve the issue.

  4. Please provide any other information you would like to share.