Feedback and Hazards Identification Form
Feedback, Unsafe Act, Unsafe Condition
Name
First Name
Last Name
E-mail
example@example.com
Company / Branch
Headquarters (KL)
Sarawak
Indonesia
Philippines
Others
Please provide company / location name if you tick 'Others' in the above list.
Division
Sales and Technical
Recruitment
Accounts
Human Resources
Top Management
IT
Building / Infra
Administration
Others
Visitors
Please provide description if selected 'Others'
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location of Findings
Office
Field Site
Others
Specific Location
Office
Warehouse
Facilities Surrounding Area
Process Area
Field Worksite
Others
Specific location for the report
Specific location if selected 'others'
Report Category
Unsafe Act
Unsafe Condition
Safe Act
Safe Condition
Near Miss
General Feedback
Report Description
Hazard, UAUC, Feedback Description and Explanation
Corrective Action Taken / Suggestion for Recommendation Action
Description for Corrective Action / Recommendation Action Taken
Upload File / Image
Browse Files
Cancel
of
Submit Form
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