Safety Hazard Reporting & Suggestions Form

Please upload a photo of the hazard (Optional)

POSSIBLE CONSEQUENCES

Possible consequences if left unchecked (injuries/damage) (Optional)

Description of contributing factors (Optional)

Probability of possible consequences (Optional)
Improbable (not likely an accident/incident will occur under any circumstance)Remote (accident not expected to happen under normal circumstances)Possible (might occur some time in the future)Likely (will probably occur frequently or has occurred frequently in the past)

Rationale (Optional)

Severity of possible consequences (Optional)
Minor (Nuisance, use of emergency procedures, minor incident)Major (Serious incident, injury, equipment damage, environmental impact)Hazardous (Serious injury, major equipment damage, large or ongoing environmental impact)Catastrophic (Death, equipment destroyed)

MITIGATION MEASURES

How do you think this hazard could be mitigated? (Optional)

YOUR INFORMATION

Disclosing your name and personal information is optional. If you would like a follow up contact about a possible resolution, please leave your information here. All hazard reports and suggestions are taken seriously and choosing not to identify yourself has no bearing on that.

Your name (Optional)

Department/Job title (Optional)

Your e-mail (Optional)

Your phone number (Optional)

Preferred method of contact (Optional)