REPORT OF UNSAFE CONDITION OR HAZARD
Date
Name (*)
(*) Optional fields. Please note that omitting this information may limit the investigation if we are unable to contact you to ask questions, and
we may not be able to provide a report of our findings.
Job Title (*)
Phone #/Email/Mail Stop (*)
Department
Dean/Director/Chair Name and E-mail address:
Location of Hazard
Building Floor Room
Date and time the condition or hazard was observed:
Description of unsafe condition or hazard: (Attach additional sheets if necessary)
What changes would you recommend to correct the condition or hazard?
Employee Signature (*)
Management / Safety Coordinator / Safety Committee Investigation
Name of person investigating unsafe condition or hazard:
Phone #/Email/Mail Stop (*)
Result of investigation (What was found? Was condition unsafe or a hazard?) (Attach additional sheets if necessary.)
Proposed action to be taken to correct hazard or unsafe condition (Complete and attach a Hazard Correction report)
Signature of Investigating Party
Date
Note: Cal-OSHA regulations require that employees be provided with a method to report hazards anonymously. Anonymous reporting, although permitted, is
not encouraged because we will not be able to ask questions to assist with an investigation. Additionally, we may not be able to provide a report of our findings.
3. If you have questions while completing this form, contact us at (559) 278-7422.
2. Complete all parts of the form clearly and completely. Incomplete reports may delay processing.
1. Report unsafe conditions and hazards promptly! Submit the form as soon as possible
INSTRUCTIONS
