Information
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Document No.
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Brief description of the hazard
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Prepared by
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Location
Details of the Report
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ALL HAZARDS MUST BE IMMEDIATELY REPORTED TO YOUR SUPERVISOR OR CONTRACTOR IN ADDITION TO SUBMITTING THIS FORM
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Type of Report
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When was the observation made?
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Name of Supervisor
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Provide a detailed description of the report.
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Add photos?
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Has this been reported to the person who can action this report?
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Name of person reported to?
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Has the hazard been fixed?
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If yes please provide details of actions taken. Including photos if possible.
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ALL HAZARDS THAT REQUIRE ATTENTION IN LESS THAN 1 DAY MUST BE FIXED IMMEDIATELY OR YOUR SUPERVISOR OR CONTRACTOR NOTIFIED IMMEDIATELY.
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Provide any additional information or comment. Draw a sketch here if appropriate.
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Signature of Person Reporting Hazard