Appendix O: Hazard Report Form

Any hazardous condition identified by an employee or student should be reported as soon as possible.

After filling out the form, give to the Chair of the Department, 312A Sims, or to the department safety officer, 109B SIMS or the departmental secretary, 101 Sims, if the Chair is not available.

Date:

Location (room number, hallway, stairwell, etc.):

Brief Description of the hazard:

Your Name:

Received by: Date:

Action taken:

Problem solved by: Date: