Notice Of Hazard Or Near Miss Form printable pdf download

Notice Of Hazard Or Near Miss Form

Hazard Notice / Near Miss

Complete top section only and give to your Supervisor

and Departmental Safety Officer

1. To (Supervisor/Manager): ____________________________________________________________

2. Date: ______________________________________ Time:_________________________________________

3. Location of hazard: ____________________________ Campus or Area: _____________________________

4. The hazard is (what could or did happen):

5. How can it be fixed?

6. Reported by: ______________________________________________________________________________

7. Email: __________________________________________ Phone: _________________________________

Department or Section to Complete:

Proposed Action:______________________________________________________________________________

____________________________________________________________________________________________

Hazard is significant

Unit hazard register updated

Person reporting informed

Form copied to Office of the Deputy Vice Chancellor

Form copied to Health and Safety office

Name of Supervisor or Department Safety Officer___________________________________________________

Signature:_____________________________________

Date:____________________________

See Health and Safety web site for more information

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Notice Of Hazard Or Near Miss Form