Appendix E — Employee Hazard Report
Employee Hazard Report
3F Construction LLC • 202 N. Justine Street, Chicago, IL 60607 • (312) 296-4855
Use this form to report an unsafe act or condition, or to suggest a safety improvement. Action will be taken whether the form is signed or not. Give the completed form to any supervisor or the Safety Coordinator, or submit it anonymously.
Unsafe act or condition observed:
______________________________________________________________________________________
______________________________________________________________________________________
Location (project / area) __________________________________________________
Proposed solution:
______________________________________________________________________________________
Date submitted ____________________ Signature (optional) ____________________________
— Safety Coordinator / management use below this line —
Evaluation and plan of action:
______________________________________________________________________________________
______________________________________________________________________________________
Target completion date ____________________ Date completed ____________________
Signature ______________________________ Response given to reporter on ____________________