Each submitted Hazard form, during a given Month, is eligible for a cash award of $20.00 voted for by the Safety Committee members and an additional $20.00 for the most submissions by an individual in any given Month. In recognition of your decision to be actively involved in our Center Safety culture, each person that submits this form will receive a complimentary (FREE) gift from the Safety Officer. >Hazard/Near Miss Recognition program is to allow Students/Staff to inform the Safety Officer of any existing Safety Hazards on Center, so that we can eliminate them. > A Near Miss is an INCIDENT that happened, that could have been an ACCIDENT. Us this information to identify a Safety Hazzard or near miss.
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Title Page
Site conducted
What is the nature of the Hazard/Near Miss
Add media
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Discovered on
Hazard/Near Miss discovered by
Staff
Student
Other
Center Safety Officer
Hazard/Near Miss
HAZARD
NEAR MISS
MAINTENANCE ISSUE
IT Dept. Issue
OTHER
Safe Practice
Deficiency Finding
Please complete by and notify the Safety Officer by email once the Hazard/Near Miss has been corrected.
Please complete by and notify the Safety Officer by email once the Hazard/Near Miss has been corrected.
Please complete by and notify the Safety Officer by email once the Hazard/Near Miss has been corrected.
Precise location
Notification will be sent to
CENTER DIRECTOR
DEPUTY CENTER DIRECTOR
Department Manager
MAINTANENCE SUPERVISOR
IT Dept.
SAFETY OFFICER
Community Life Coordinator
Work Order will be submitted by the CSO
Other > Please specify in notes
Who is the responsible Supervisor or Building Manager
Issue has been corrected?
Compliant
Non-Compliant
N/A
Not Inspected
Follow-Up Needed.
Items Corrected.
Was Work Order # entered?
Is this Hazard/Near Miss submitted eligible for the Cash Reward?
Yes
No
N/A
Rejected, Please see notes below
Name of Staff or Student
Staff or Student ID #
Vance Schuening
3. Hazard / Near Miss Report Form
Each submitted Hazard form, during a given Month, is eligible for a cash award of $20.00 voted for by the Safety Committee members and an additional $20.00 for the most submissions by an individual in any given Month. In recognition of your decision to be actively involved in our Center Safety culture, each person that submits this form will receive a complimentary (FREE) gift from the Safety Officer. >Hazard/Near Miss Recognition program is to allow Students/Staff to inform the Safety Officer of any existing Safety Hazards on Center, so that we can eliminate them. > A Near Miss is an INCIDENT that happened, that could have been an ACCIDENT. Us this information to identify a Safety Hazzard or near miss.
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions.
The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice.
You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction.
You should independently determine whether the template is suitable for your circumstances.
