Hazard Report Form

Reporter Name

Date of Observation*

Location of Hazard*

Hazard Type*

Slip / Trip / Fall

Electrical

Chemical

Fire

Ergonomic

Equipment Malfunction

Other

Severity Level*

Low - Minor inconvenience

Medium - Could cause injury

High - Immediate danger

Critical - Life threatening

Description of Hazard*

Has anyone been injured?*

Suggested Corrective Action

What is this form?

A hazard reporting form for employees and visitors to report unsafe conditions, potential dangers, or near-miss incidents.

Safety officers, facility managers, HR teams, and organizations with workplace safety programs.