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APPENDIX 9-3
SUGGESTED FORMS FOR EMPLOYEE REPORTING OF HAZARDS
EXAMPLE #1 - EMPLOYEE REPORT OF HAZARD
| EMPLOYEE REPORT OF HAZARD |
Hazard or problem ______________________________________________________________________________
Suggested action ______________________________________________________________________________
Department: __________________________ EMPLOYEE: COMPLETE THE ABOVE AND GIVE TO SUPERVISOR
Date: ____________________________
Hour: ____________________________
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Action taken: ______________________________________________________________________________
Department: _______________________ SUPERVISOR: COMPLETE AND GIVE TO MANAGER
Date: _____________________
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Review/Comments ______________________________________________________________________________
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| Manager’s Signature ___________________________________ Date _____________________ |
FOLLOW-UP DOCUMENTATION
(Can be used as part of the preceding form or separately in companies whose employees are not
required to put in writing the report of hazard.)
Hazard ________________________________________________________________________
Possible injury or illness __________________________________________________________
Exposure __________________________________ Frequency __________________________
Duration ______________________________________________________________________
Interim protection provided _______________________________________________________
Corrective action taken ___________________________________________________________
Follow-up check made on _________________. Any additional action taken? _________________
Signature of Manager or Supervisor _________________________________________________
Date _________________
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Three month follow-up check made on ______________________________________________.
Is corrective action still in place? _____________________________
YES NO
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EXAMPLE #2 - REPORT OF SAFETY OR HEALTH PROBLEMS
| REPORT OF SAFETY OR HEALTH PROBLEMS |
DESCRIPTION OF PROBLEM (INCLUDE EXACT LOCATION, IF POSSIBLE)
______________________________________________________________________________
NOTE ANY PREVIOUS ATTEMPT TO NOTIFY MANAGEMENT OF THIS PROBLEM AND THE PERSON NOTIFIED
______________________________________________________________________________
DATE: ______________ OPTIONAL: SUBMITTED BY ____________________________________
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SAFETY DEPARTMENT FINDINGS ___________________________________________________
_____________________________________________________________________________
ACTIONS TAKEN
______________________________________________________________________________
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SAFETY COMMITTEE REVIEW COMMENTS
_______________________________________________________________________________
ALL ACTIONS COMPLETED BY _______________________________________________________
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EXAMPLE #3 - EMPLOYEE REPORT OF HAZARD
I believe that a condition or practice at the following location is a job safety or health hazard.
Is there an immediate threat of death or serious physical harm? Yes No
Provide information that will help locate the hazard, such as building or area of building or
the
supervisor’s name. _________________________________________________________________
Describe briefly the hazard you believe exists and the approximate number of employees exposed
to it.
________________________________________________________________________________
If this hazard has been called to anyone’s attention, as far as you know, please provide the
name of the
person or committee notified and the approximate date.____________________________________
Signature (Optional) ________________________________________ Date ___________________
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Management evaluation of reported hazard _______________________________________________
Final action taken
_________________________________________________________________________________
All actions completed by ______________________________________________ initials __________
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