Section 1 of 1
Safety Report
Please fill out this form to report any safety incidents, hazards, or concerns.
Date of Incident/Observation
Date of Incident/Observation
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Rating
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Checkbox grid
Date
Time
Answer key
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Time of Incident/Observation
Time of Incident/Observation
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
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Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Location of Incident/Observation
Location of Incident/Observation
Question Type
Short answer
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Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
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Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Type of Incident/Observation
Type of Incident/Observation
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Near Miss
Injury
Property Damage
Hazardous Condition
Unsafe Act
Environmental Incident
Other (Please specify in description)
Add option
or
add "Other"
…
Answer key
(0 points)
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Description of Incident/Observation (Please provide as much detail as possible)
Description of Incident/Observation (Please provide as much detail as possible)
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Witnesses (Names and Contact Information)
Witnesses (Names and Contact Information)
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
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Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Severity of Incident/Observation
Severity of Incident/Observation
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Minor (No injury or damage)
Moderate (Minor injury or damage)
Serious (Significant injury or damage)
Critical (Life-threatening injury or major damage)
Add option
or
add "Other"
…
Answer key
(0 points)
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Recommended Corrective Actions
Recommended Corrective Actions
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Your Name (Optional)
Your Name (Optional)
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Your Contact Information (Optional)
Your Contact Information (Optional)
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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