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Appendix 9-3

Appendix 9-3

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: ____________________________

Action taken: ______________________________________________________________________________

Department: _______________________ SUPERVISOR: COMPLETE AND GIVE TO MANAGER

Date: _____________________

Review/Comments ______________________________________________________________________________
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

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 ____________________________________

SAFETY DEPARTMENT FINDINGS ___________________________________________________

_____________________________________________________________________________

ACTIONS TAKEN

______________________________________________________________________________

SAFETY COMMITTEE REVIEW COMMENTS

_______________________________________________________________________________

ALL ACTIONS COMPLETED BY _______________________________________________________
 

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 __________