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Hazard Report Form
Occupational Health & Safety
* filled is mandatory to fill the report
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* Indicates required question
Report Unsafe Condition
Safety Instructions
To maintained quality of Hazard Report
Date
*
MM
/
DD
/
YYYY
Area/Location of Hazard
*
Your answer
Description of Hazard
*
Your answer
Hazard Category
Choose
Mechanical
Electrical
Biological
Chemical
Physical
Moving Machinary
Orthers
Corrective/Preventive Action
*
Your answer
Responsible (Department/Area)
*
Choose
Mechanical
Electrical
Production
Admin
Health & Safety
Environment
Store
HR
Name of Reporter
Your answer
Tentative target date to Complete Hazard
MM
/
DD
/
YYYY
Remarks
Your answer
Submit
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