University Safety Hazard Report
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1
2SHEPHERD UNIVERSITY HAZARD REPORT
TO:
FROM:
DEPARTMENT:
PHONE:
Supervisor, Safety Committee
(EMPLOYEE’S NAME)
Administration, Other
SUPERVISOR NOTIFIED:
Related Operating Procedures
All Affected Employees Notified:
DATE
/
/
Yes
No
Reviewed:
Yes
No
Yes
No
SUPERVISOR ACKNOWLEDGMENT
I certify that I have reviewed the information contained in this hazard report and will take the necessary steps to ensure
correction.
* Further detailed on attachment:
Yes
No
Name:
Signature:
Title:
Date:
Time:
MACHINE HAZARD: (Narrative)
(not to be used for routine maintenance)
Has the Machine been reported to maintenance?
Yes
No
Date/Time:
Has the Machine been Locked Out/Tagged Out?
Yes
No
Date/Time:
DESCRIPTION OF HAZARD:
(Other than machine hazard)
(Narrative)
CORRECTIVE ACTION RECOMMENDATIONS:
(Other than machine hazard)
(Narrative)
Do Not Write Below This Line
REPORT NUMBER:
ESTIMATED COMPLETION DATE:
DATE RECEIVED:
FORWARDED TO:
DATE:
PERSON RESPONSIBLE:
Accident Investigation Program
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Parent category: Business