Hazard Identification Form

The purpose of this form is to report potentially hazardous situations to the Environmental Health & Safety (EH&S) Department. According to Palomar College's Injury and Illness Prevention Program, EH&S is to provide a system for workers to anonymously inform management about workplace hazards. This form fulfills that need.

Please provide the following information:
In order to most accurately and promptly address your concern, please be as detailed and specific as possible.
Date:*
Site of Hazard:*
Hazard Description*
Describe briefly the hazards(s) which you believe exist. Include the approximate number of employees exposed to or threatened by each hazard:
Hazard Location*
Specify the particular building or worksite where the alleged violation exists:
Hazard Mitigation
Describe interim action that you took to mitigate the hazard, if any:
This condition has been brought to the attention of:
(Choose all that apply)
- Supervisor
- Other Government Agency (specify in "Comments")
I am a(n):*
- Former Employee
- Current Employee
- Representative of Employees
- Other (specify in "Comments")
Comments:
Additional Information:
NOTE: You are NOT required to provide your personal information in order to submit a hazard concern. By clicking "Yes" when asked if you would like to be contacted directly regarding your concern, you will be given the option to submit personal information. If you wish to remain anonymous, either click "No" or continue to "Submit."
Would you like to be contacted directly regarding your concern?
- Yes
- No
Complainant Name:
Job Title:
Department:
Complainant Work Phone:
Complainant Email Address:

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Facilities Department

Hazard Identification Form

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Additional Information:

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