Hazard Report Form

Hazard Report Form
Date Hazard Noticed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reported By:   First Name   Last Name
Reported To:   First Name   Last Name
Location of Hazard:
Category:   Near Miss   Workplace Hazard      Hazardous Work Practice
Take Photo
Description of the Hazard:
What needs to be done? By whom? When?
Signature
Should be Empty: