Hazard Report Template

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Department o f Public Safety
Workplace Safety & Health Division Safety Hazard Reporting Form
HAZARD REPORTING
FORM
Owens Community College is committed to maintaining a safe work environment. A safe work environment
is one which is free from accidents, injuries and work-related illnesses. All employees must work together to
create and maintain a safe environment for all employees, students and visitors. Owens Community C ollege is
committed to strict compliance of all Federal, State and Local Laws concerning worker health and safety.
Owens State Community College employees may use this form to report safety issues to the Department of
Public Safety, Workplace Safety & Health Division. The Safety Department will investigate the safety
issue/complaint to determine what action needs to be taken. This form can be submitted anonymously.
Employees are advised that it is illegal for an employer to take any action against an employee in reprisal for
exercising their rights to report safety issues.
Date:
Time:
Employee’s
Name:
(Optional)
Department:
(Optional)
Phone
#
and/or
Email:
(Optional)
Describe the unsafe condition or practice:
Location:
_
(Building, Floor, Room #, Department, etc.)
Has this matter been reported to your supervisor? Yes No
Do you wish to be notified of action taken: Yes No (If yes, please make sure contact information is available).
(Send completed form to the Department of Public safety, Workplace Safety & Health Division.)
DPS Use Only:
Corrective Action Taken:
Date:
Time:
By:
Subject: Safety Hazard Reporting Form Effective Date: January 2012
Procedure: S.2.A Revised: New
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