A short form any employee can use to report an unsafe condition before someone gets hurt.
Most injuries are preceded by a hazard someone noticed and did not report, often because there was no simple way to do it or no sign that reports led anywhere. A one-page hazard report fixes the first problem. A visible close-out fixes the second.
Use it for physical hazards such as spills, damaged equipment, blocked exits or exposed wiring, and for unsafe practices such as skipped lockout steps. A hazard report is not an incident report: it is filed before anyone is hurt. If someone was injured or a near miss happened, use your incident process as well.
Employers should make clear that reporting hazards is welcome and that no one will be punished for a good-faith report.
16 items. Keep it on a tablet, or print a copy for the clipboard.
| Field | What to write |
|---|---|
| Location | Back stockroom, aisle 3 |
| Hazard | Top shelf bracket bent; boxes leaning outward |
| Immediate action | Area taped off, heavy boxes moved to floor |
| Risk rating | Likelihood 3 × severity 4 = 12, high |
| Corrective action | Replace bracket and add load-limit label; owner: maintenance; due Thursday |
| Closed | Thursday 2 p.m., checked by store manager |
A warehouse picker notices that a dock plate lip is cracked and catches pallet jack wheels. She marks it with a cone and fills in the form on her phone at 9:10 a.m. The shift supervisor rates it 3 × 4 = 12, closes that dock door for the day and asks maintenance to replace the plate. It is replaced the next morning, and the picker gets a message saying the dock is back in use.
| Score | Priority | Response |
|---|---|---|
| 1 to 4 | Low | Fix within 30 days |
| 5 to 9 | Medium | Fix within 7 days |
| 10 to 16 | High | Control today, fix within 48 hours |
| 20 to 25 | Critical | Stop the work or close the area now |
Write your own bands into the form so every supervisor rates the same way.
Section 11(c) of the Occupational Safety and Health Act bars retaliation against employees who raise safety concerns, and an employee who believes they were punished has 30 days to file a complaint with OSHA. A visible promise on the form that good-faith reports are welcome does more for reporting rates than any poster.
A hazard report is filed before anything happens. An incident report records an injury, damage or near miss after it occurs.
They can be, and allowing it may increase reporting. Anonymous reports are harder to follow up, so ask for a location and photo where possible.
Usually the direct supervisor, with a safety lead or manager reviewing high-risk items.
Follow your company’s record retention policy and any rules that apply to your industry and location.
Employees can fill in and sign forms like this in the EZTime app, and the signed copy lands in their digital employee file. Book a demo to see it with your team.