Please provide as much contact information as you believe is necessary:
Campus/Facility:
Date:
Imminent hazards posing an immediate danger to life and health should be reported immediately to the EHS office (x84728) or your supervisor.
Location of Hazard (incl. building and room #):
Description of Hazard:
Recommendation for Correction:
Has this hazard been reported to your supervisor? (Yes/No)
Optional
Employee First Name: Employee Last Name: Department: Telephone:
Note: It is illegal for any California employer to take action against employees who exercise their right under law to report unsafe conditions.