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Office of Occupational Safety & Health

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Report of Work Area Safety or Health Hazards

Everyone in a workplace shares responsibility for ensuring that their work environment is safe and healthy. Some hazards pose an immediate danger and others take a longer time to become apparent. But both types of hazards must be fixed. According to DAO 209-4 Occupational Safety and Health Program, a workplace hazard is defined as the potential for harm resulting from an accident/incident. In practical terms, a hazard often is associated with a condition or activity (physical, chemical, or biological) that has the potential to cause illness, injury, or death to a person, and/or if left uncontrolled, can result in an accident/incident (e.g., injury, illness, and/or property damage/loss). Identifying hazards and eliminating or controlling them as early as possible will help prevent accidents/incidents.

If you are aware of a hazard in your workplace, you should report it promptly to your supervisor, your Bureau Safety Manager or area safety representative. Once a hazard has been identified, your supervisor has a duty to assess the problem and eliminate any hazard that could injure workers.

INSTRUCTIONS:

Complete the form as accurately and completely as possible. Describe each hazard you think exists in as much detail as you can. If the hazards described in your report are not all in the same area, please identify where each hazard can be found at the worksite. If there is any particular evidence that supports your suspicion that a hazard exists (for instance, a recent accident or physical symptoms of employees at your site) include the information in your description. If you need more space than is provided on the form, continue on any other sheet of paper.

After you have completed the form, return it to your supervisor. Also provide a copy to your Bureau Safety Manager or area safety representative.

Establishment Name

 

Establishment Phone

 

Establishment Address

 

Responsible Supervisor or Management Official in Charge

 

Bureau Safety Manager or area safety representative

 

Type of Establishment or Facility (describe)

Describe briefly the work operations performed.

Hazard Description and Location

Describe briefly the hazard(s) which you believe exist. Include the approximate number of employees exposed to or threated by each hazard. Specify the particular work operation, building or worksite where the hazard(s) exits.

OSHA Standard Violation:

___ YES ___ NO

___ N/A

To your knowledge, is the Hazard a violation of an OSHA standard or safety best practice? Please describe:

Hazard Previously Reported:

___ YES ___ NO

Has this condition been brought to anyone’s attention before? If YES, describe the circumstances:

Your Name (optional)

 




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