HAZARD INFORMATION

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
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.