Employee Hazard Report

An employee hazard report from can be beneficial in facilitating the proper reporting of potential hazards and help in preventing possible accidents and injuries to people or property which both leads to economic losses for the organization.

Sample Employee Hazard Report Form
When observing any hazard or situation that affects safe operations or quality production, fill out this form and return it to the Safety Manager.

1. Hazard Or Situation Observed: a. Describe the facts.

2. Name/Title:
a. Optional information as to your area of responsibility

3. Date Observed:a. Time of day?
b. What shift?

4. Circumstances:
a. What exactly did you see:
b. What accident or mishap could this lead to:

5. Supplemental Data:
a. List any other important information pertaining to the occurrence such as vehicle/equipment involved, environmental factors, location, frequency, etc.

6. Feedback
a. I desire feedback on corrective actions taken
b. I do not desire feedback on corrective actions taken

Starting with employees on the front lines to report known observable hazards is one of the first steps in preventing accidents.

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