Hazard Report Form

Hazard Report

The completion and execution of this Personal Injury Hazard Report does not in any way constitute admission of liability in respect of the alleged HAZARD the subject of the Report and is without prejudice.

What, When and Where

Hazard Date

Type of Hazard

Specific Hazard Location:

Day of the week:

Time of day:

If outside the building, describe the weather conditions

If inside the building, describe the lighting level

Reported

Reported by: Name

Reported to: Name

Time:

Position: