THIS FORM IS FOR STAFF/VISITORS TO PROVIDE A SAFETY SUGGESTION, REPORT AN EMPLOYEE INJURY OR REPORT A HAZARDOUS WORKPLACE CONDITION OR PRACTICE. THIS FORM WILL BE SENT TO THE SAFETY TEAM.
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Start of Report
TYPE OF REPORTING
CONDITION
CHEMICAL
ENVIRONMENTAL
FIRE SAFETY
PHYSICAL SAFETY
TRANSPORTATION
WALKWAY/DOCK SAFETY
OTHER
POTENTIAL INJURY
BURN
CHEMICAL
CUTS, ABRASION
ELECTRICAL
EXPOSURE
SMASH
STRAIN,SPRAIN
STUCK BY OBJECT
SLIP, TRIP, FALL
OTHER
PLEASE EXPLAIN:
HAZARD LOCATION (BUILDING, ROOM, OTHER DESCRIPTION)
SUGGESTION FOR IMPROVING SAFETY/CORRECTION OF HAZARD
REPORTED BY
YOUR NAME
DATE & TIME OF REPORT
UPLOAD OF PICTURE SAFETY ISSUE/CONCERN
* PICTURE
Untitled Page
Chris Jones
Employee Safety and Accident Report
THIS FORM IS FOR STAFF/VISITORS TO PROVIDE A SAFETY SUGGESTION, REPORT AN EMPLOYEE INJURY OR REPORT A HAZARDOUS WORKPLACE CONDITION OR PRACTICE. THIS FORM WILL BE SENT TO THE SAFETY TEAM.
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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.