Please complete the following form for safety hazard reporting or suggestions.
Description of hazard (Required)
Areas/Departments affected (Required)
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)
How do you think this hazard could be mitigated? (Optional)
Your name (Optional)
Department/Job title (Optional)
Your e-mail (Optional)
Your phone number (Optional)
Preferred method of contact (Optional)
If an error occurs while submitting this form, please press the submit button again.
For questions or concerns about submitting this form, please contact:
Mike Thames Safety & Security Compliance Specialist 941.639.1101 ext: 142 [email protected]