BCC Safety Hazard Report

• Conducted on

  Date

• Prepared by

BREITBACH CONSTRUCTION SAFETY HAZARD REPORT

• WHAT TYPE OF HAZARD?

  Select UNSAFE ACT UNSAFE CONDITION UNSAFE EQUIPMENT UNSAFE USE OF EQUIPMENT NEAR MISS

  • UNSAFE ACT
  • UNSAFE CONDITION
  • UNSAFE EQUIPMENT
  • UNSAFE USE OF EQUIPMENT
  • NEAR MISS

• DATE AND TIME OF INCIDENT

  Date

• DESCRIPTION OF INCIDENT OR POTENTIAL HAZARD (WHO, WHAT, WHERE, WHY)

• PICTURE OF HAZARD

  Media

HAZARD INVESTIGATION

• CAUSES THAT LED TO INCIDENT(PRIMARY AND CONTRIBUTING)

• WHAT ACTION DID YOU TAKE TO CORRECT THE HAZARD?

  Select REMOVE REPLACE REPAIR RETRAIN

  • REMOVE
  • REPLACE
  • REPAIR
  • RETRAIN

• DESCRIPTION OF ACTION TAKEN

• SIGNATURE

  Sign