Hazardous Condition Report
This Section to be completed by Employee:
Please use this form to report unsafe or uncorrected conditions which could endanger employees or students of this
district, or to request assistance from the District Safety Committee or District Safety Coordinator. You may report
conditions anonymously.
Do not use this form in lieu of a work order to maintenance. Emergency conditions should always be reported
immediately to your supervisor and/or the maintenance department.
Return this completed form to the District Safety Coordinator.
District: San Luis Obispo County Community College Location: SLO NCC Other
Today’s Date: Date Condition Identified:
Your Name: (Optional): Phone Number (Optional):
Has this condition been previously reported? Yes No Unknown
If yes to above, to whom?
Nature of Hazardous Condition:
Who is this affecting?
What is happening?
When and how often does it occur?
Where exactly is the hazardous condition? (Room number, name, restroom, playground, part of building, etc.)
Why is this occurring?
