LSC - CMS Form - Hazard Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Hazard Information

• Unsafe/ Unhealthy Act or Condition

  Yes

  No

  N/A

• Near Miss

  Yes

  No

  N/A

• Minor Property Damage

  Yes

  No

  N/A

• Skills Enhancement/ Training Opportunity

  Yes

  No

  N/A

• Minor Accident

  Yes

  No

  N/A

• Environmental Hazard/ Event*

  Yes

  No

  N/A

• SWP/ Lockout Improvement

  Yes

  No

  N/A

• Road Hazards

  Yes

  No

  N/A

• Rock Instability

  Yes

  No

  N/A

• External/ Internal Communication

  Yes

  No

  N/A

• Snag

  Yes

  No

  N/A

• Brushing Out

  Yes

  No

  N/A

• Feedback

  Yes

  No

  N/A

• Map of Location: Yes No NA Attachment:

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

• Description:

Action

• Person Responsible

• Due Date

  Date

• Date Completed

  Date

• Name:

• Signature:

  Sign

• Date:

  Date

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• Supervisor Name:

• This form should be filled out, and distributed in to your Supervisor and Safety immediately. Supervisors are to follow-up and respond to the person reporting the hazard or issue within one week of receiving the report