Maui Bay Villas Phase 3
Project #6601081
Hazard / Near Miss or Positive Observation Form
Name
*
Company
*
Are you reporting a hazard/near miss or a positive observation?
*
Hazard/ Near miss
Positive Observation
Location of Hazard
*
Hazard/ Near miss details
*
Any corrective actions taken?
*
Is further action required to make the area safe?
*
Yes
No
Recommended action needed?
*
Have you alerted your supervisor?
*
Yes
No
Location of positive observation
*
Positive observation details
*
Worker's Name
*
Worker's Company
*
Submitted By:
*
Name
Contact Number
Company
Submit
Should be Empty: