Safety and Incident Reports

Workplace Safety Hazard Reporting Form

Complete this form to report a Safety Hazard to help the company investigate and respond appropriately to Safety Hazards in a timely manner. This report will be forwarded to personnel on the Kodiak Safety Teams who have been designated to receive this information. Please describe the hazard in detail so Operations or the Safety Team can gain an accurate understanding of the hazard as this will aid Kodiak in its investigation and mitigation efforts.

Section 1: Information About the Person Completing This Report

Name

(Leave Blank If Reporting Anonymously)

Job Title(Required)

Date Submitted(Required)

Section 2: Hazard Information

Date of Hazard(Required)

Time of Hazard(Required)

Location of Hazard(Required)

Include job name number if applicable

Describe Specific Area of Location(Required)

Be Specific e.g. NW corner of Fabrication Area, East Parking Lot, Building C Roof etc.

Describe the Type of Hazard(Required)

e.g. Unprotected Hole, Unsafe Scaffold, Defective or Damaged Ladder, Unsafe Scaffold, etc.)

Describe the Safety Hazard in Detail(Required)

If possible, recall and describe circumstances surrounding the hazard including but not limited to, other Subcontractor removed scaffold planks and guardrails, GC left skylights unprotected, coworker instructed to work alone on roof, was told by foreman to work without Fall Protection, etc.

Phone

This field is for validation purposes and should be left unchanged.