Workplace Safety Report Form / Campus Life / Westminster College

Contact Information of Person Submitting Report:

Name

Position/Title

Department

Phone

Date of Report

Location / Area of Concern

Condition

Work Habit

Equipment

Work Area

Fire Hazard

Electrical Hazard

Water Hazard

Proper Storage

Miscellaneous

Brief Description of Concern (Please state in detail what you observed):

Recommended Action (Please state in detail what you believe may resolve the concern):

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