Hazard Registration Form

When in doubt, always report | Safety first

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Hazard Registration Form

If you encounter an unsafe situation without an incident having occurred, you can report this using this form. Based on this report, a risk analysis will be made and improvements will be proposed, evaluated and realized.

Titel hazard:*
Date of identified hazard*
Hidden
Tijd

: UU

MM
Time of identified hazard
minutes
Location of identified harzard*
Brief description of the identified hazard*
To your knowledge has this hazard previously caused an incident?*
Brief explanation of your answer
Possible consequenties when nothing is done about this
Your proposal for measures which could be taken
Details of the reporting party
Filling in these details is not compulsory. Never the less it can help the safety committee to ask additional questions. After investigation has been completed, the identifying data will always be removed from the form.
Name
First Last
Telephone number
E-mail address
Date of report
DD slash MM slash JJJJ
CAPTCHA
Name
Dit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.

Hazard Registration Form

Hazard Registration Form

Details of the reporting party