UNSAFE CONDITION REPORT FORM
ENVIRONMENTAL HEALTH & SAFETY
Room or area in which unsafe condition exists: _________________________________
Name_________________________ Dept: ___________________________________
Date unsafe Act/Condition Observed: _________________________________________
Please provide a detailed description of the unsafe act/condition: ___________________ ________________________________________________________________________
________________________________________________________________________
Contributing factors (please mark all that apply)
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Lack of Guards |
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No Guard Rails |
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Inadequate Guard |
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Power Lines |
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Defective Equipment |
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Explosive Materials |
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Hazardous Arrangement |
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Damaged Equipment |
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Improper Illumination |
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Cluttered Floors |
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Unsafe Ventilation |
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Blocked Isles |
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Hazardous Methods/Procedures |
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Blocked Fire Exits |
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Insufficient Lighting |
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Poor Housekeeping |
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Too much Light |
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Equipment Failure |
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Concentration of fumes/dust/gases |
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Overloaded Platforms |
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Abnormal temperature and humidity |
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Overloaded vehicles |
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Horseplay |
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Other ( ) |
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Lack of Personal Protective Equipment |
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How do you think this problem can be corrected: ________________________________
________________________________________________________________________
________________________________________________________________________
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