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University of California, Berkeley
Injury & Illness Prevention Program - Form 1

REPORT OF UNSAFE CONDITION OR HAZARD

Department:

I. Unsafe Condition or Hazard

Name: (optional)

Job:

 

Title:

Location of Hazard:

Building:

Floor:

Room:

Date and time the condition or hazard was observed:

Description of unsafe condition or hazard:

What changes would you recommend to correct the condition or hazard?

Employee Signature: (optional)

Date:

 

II. Management/Safety Committee Investigation

Name of person investigating unsafe condition or hazard:

Results of investigation (What was found? Was condition unsafe or a hazard?): (Attach additional sheets if necessary.)


Proposed action to be taken to correct hazard or unsafe condition: (Complete and attach a Hazard Correction Report, IIPP Form 4)


Signature of Investigating Party:

Date:


IIPP - Form 1 Completed copies of this form should be routed to the appropriate supervisor and department Safety Committee, and must be maintained in department files for at least one year.
Rev. 10/02/01
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