Unsafe Conditions Report

This form is to be completed by employees and returned to their supervisor. This form must reach the department no later than one (1) day after completion for serious unsafe conditions and no more than three (3) days for other unsafe conditions. Conditions which may cause immediate injury should be reported to your supervisor by phone immediately.

MM slash DD slash YYYY
Time
:
Name of Reporting Person
What actions do you recommend for correcting the unsafe condition?

IMPORTANT: It is very important to investigate the accident as opposed to the results of the accident. For example, you are not investigating a broken arm, but the factors leading to it. An accident or incident can be a fall, slip, trip, slide, strike against or other contact, being caught in or between, eruption or explosion, burn, or improper movement. Results can range from a simple annoyance to a fatality. The examples of corrective actions are designed to help you determine some possible actions. It is important that some effective action is taken, including improving management systems and personal performance as management personnel.