Environmental Health and Safety Department
The purpose of this form is to report potentially hazardous situations to the Health and Safety Department.
Please provide the following contact information:
First Name Last Name Title Department Work Phone FAX E-mail
Enter the date:
-- mm/dd/yy
Status
FACULTY STAFF STUDENT OTHER
Please Describe the Nature and Location of the Hazard
Describe Interim Action That You Took To Mitigate the Hazard, if any.