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University of California, Berkeley
Injury & Illness Prevention Program - Form 4

HAZARD CORRECTION REPORT

Department:

This Form should be used in conjunction with the "Report of Unsafe Condition" form (IIPP Form 1),as appropriate, to track the correction of identified hazards.

All hazards should be corrected as soon as possible, based on the severity of the hazard. If a serious imminent hazard cannot be immediately corrected, remove personnel from the area and restrict access until the hazard can be addressed.

Supervisor/Safety Coordinator Name:
Telephone Ext.:

Supervisor/Safety Coordinator Signature:

Date:

Description and Location of Unsafe Condition
Date Discovered
Required Action and Responsible Party
Completion Date
Projected

Actual




  		  
 



  		  
 



  		  
 



  		  
 



  		  
 



  		  
 



  		  
 



  		  
 



  		  
 

IIPP - Form 4

Completed copies of this form should be routed to the department Safety Committee and kept in department files for at least one year.
Rev.10/02/01

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