Brittan Duhon

SSB HAZARD REPORT

UTILIZE THIS FORM TO REPORT TO THE HSE DEPARTMENT ANY UNUSUAL OR NEW HAZARDS EMPLOYEES ARE EXPOSED TO

Use this Template

Print as PDF

Use this Template

Go digital today!

Convert your paper checklists into digital forms

Scan this QR code to use this paper checklist on your smartphone or tablet or visit https://safetyculture.com/

Information

JOB INFORMATION

EMPLOYEE COMPLETING REPORT
JOB #
JOB LOCATION/ADDRESS
CURRENT DATE/TIME

HAZARD INFORMATION

DESCRIBE THE HAZARD IN DETAIL
ENTER HAZARD IMAGES
IS APPLICABLE PROTECTIVE MEASURES (PPE, ETC.) CURRENTLY AVAILABLE?
IS ANY EQUIPMENT INVOLVED IN THE HAZARD
IF YES, BRIEFLY DESCRIBE
DESCRIBE WHAT IS CURRENTLY BEING DONE TO MITIGATE THE HAZARD
DO YOU WISH TO MAKE ANY SPECIAL REQUESTS AT THIS TIME?
EMPLOYEE SIGNATURE

Brittan Duhon

SSB HAZARD REPORT

UTILIZE THIS FORM TO REPORT TO THE HSE DEPARTMENT ANY UNUSUAL OR NEW HAZARDS EMPLOYEES ARE EXPOSED TO

Use this Template

Print as PDF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. 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.