Brittan Duhon

SSB HAZARD REPORT

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

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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

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