LSC - CMS Form - Hazard Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Hazard Information

• Type of Hazard

  Select Unsafe/ Unhealthy Act or Condition Skills Enhancement/ Training Opportunity SWP/ Lockout Improvement External/ Internal Communication Feedback Near Miss Minor Accident Road Hazards Snag Minor Property Damage Environmental Hazard/ Event Rock Instability Brushing Out Other

  • Unsafe/ Unhealthy Act or Condition
  • Skills Enhancement/ Training Opportunity
  • SWP/ Lockout Improvement
  • External/ Internal Communication
  • Feedback
  • Near Miss
  • Minor Accident
  • Road Hazards
  • Snag
  • Minor Property Damage
  • Environmental Hazard/ Event
  • Rock Instability
  • Brushing Out
  • Other

• Description: Detailed information about the Safety Issue or Hazard

Immediate Actions Taken or Suggestions to Control or Eliminate Hazard/ Near Miss

• Hazard marked in field?

  Yes

  No

  N/A

• “No Work Zone” created in field?

  Yes

  No

  N/A

Action

• Date Assigned

  Date

• Person Responsible

• Due Date

  Date

• Date Completed

  Date

Supervisor

• 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