"Hazard Report Template - Shepherd University"

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SHEPHERD UNIVERSITY HAZARD REPORT
TO:
FROM:
DEPARTMENT:
PHONE:
Supervisor, Safety Committee
(EMPLOYEE’S NAME)
Administration, Other
SUPERVISOR NOTIFIED:
Related Operating Procedures
All Affected Employees Notified:
DATE
/
/
 Yes
 No
Reviewed:
 Yes
 No
 Yes
 No
SUPERVISOR ACKNOWLEDGMENT
I certify that I have reviewed the information contained in this hazard report and will take the necessary steps to ensure
correction.
* Further detailed on attachment:
 Yes
 No
Name:
Signature:
Title:
Date:
Time:
MACHINE HAZARD: (Narrative)
(not to be used for routine maintenance)
Has the Machine been reported to maintenance?
 Yes
 No
Date/Time:
Has the Machine been Locked Out/Tagged Out?
 Yes
 No
Date/Time:
DESCRIPTION OF HAZARD:
(Other than machine hazard)
(Narrative)
CORRECTIVE ACTION RECOMMENDATIONS:
(Other than machine hazard)
(Narrative)
Do Not Write Below This Line
REPORT NUMBER:
ESTIMATED COMPLETION DATE:
DATE RECEIVED:
FORWARDED TO:
DATE:
PERSON RESPONSIBLE:
Accident Investigation Program
SHEPHERD UNIVERSITY HAZARD REPORT
TO:
FROM:
DEPARTMENT:
PHONE:
Supervisor, Safety Committee
(EMPLOYEE’S NAME)
Administration, Other
SUPERVISOR NOTIFIED:
Related Operating Procedures
All Affected Employees Notified:
DATE
/
/
 Yes
 No
Reviewed:
 Yes
 No
 Yes
 No
SUPERVISOR ACKNOWLEDGMENT
I certify that I have reviewed the information contained in this hazard report and will take the necessary steps to ensure
correction.
* Further detailed on attachment:
 Yes
 No
Name:
Signature:
Title:
Date:
Time:
MACHINE HAZARD: (Narrative)
(not to be used for routine maintenance)
Has the Machine been reported to maintenance?
 Yes
 No
Date/Time:
Has the Machine been Locked Out/Tagged Out?
 Yes
 No
Date/Time:
DESCRIPTION OF HAZARD:
(Other than machine hazard)
(Narrative)
CORRECTIVE ACTION RECOMMENDATIONS:
(Other than machine hazard)
(Narrative)
Do Not Write Below This Line
REPORT NUMBER:
ESTIMATED COMPLETION DATE:
DATE RECEIVED:
FORWARDED TO:
DATE:
PERSON RESPONSIBLE:
Accident Investigation Program
INVESTIGATION OF HAZARD
IMMEDIATE ACTION TAKEN
FOLLOW-UP ACTION TAKEN
PERSON CONTACTED:
DATE:
TIME:
REMARKS:
NEW ESTIMATED COMPLETION DATE:
PERSON CONTACTED:
DATE:
TIME:
REMARKS:
NEW ESTIMATED COMPLETION DATE:
SUMMARY OF INVESTIGATION:
ACKNOWLEDGMENT
I certify that I have investigated the hazards reported in this hazard report and will take the necessary steps to ensure
correction of safety deficiencies noted.
* Further detailed on attachment:
 Yes
 No
Name:
Signature:
Title:
Date:
Time:
REPORT FORM RETENTION INFORMATION
ATTACHMENTS
Permanent Retention File:
Location:
*Yes 
No 
Date Filed:
Filed By:
*See Following Pages
Accident/Hazard Investigation Program
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