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 _________________ ******************************************************************** 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 __________