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Workplace Safety and Concerns Form Template

Address Employee Safety with Ease and Confidence

Feeling uncertain about workplace safety issues can lead to frustration among your team. This Workplace Safety and Concerns Form Template helps you collect vital feedback from employees, ensuring their safety concerns are heard and addressed. You can quickly customize it for specific needs, enhance communication, and promote a safer work environment, all while being accessible on any device. Use this template to empower your staff to express concerns, foster a culture of safety, and streamline your response processes. Experience seamless form creation and start improving workplace safety.

Use this Template (FREE) Live Preview
Do you prefer to report anonymously?
Yes
No
Full name
Work email
Phone number
Department or team
Role or job title
Preferred contact method
Email
Phone
Either
Do not contact me
What type of report is this?
Hazard observed
Near miss
Incident with injury/illness
Behavioral or safety concern
Property damage only
Other or not sure
Date of event or observation
Approximate time of event (e.g., 2:30 PM)
Location type
Specific location details (area, room, equipment ID)
Describe what happened or what you observed
Hazard category
What was the outcome?
No injury or illness
First aid only
Medical treatment
Lost time
Property damage only
Not sure or prefer not to say
Estimated potential severity if unaddressed
Low
Moderate
High
Critical
Not sure
Likelihood of recurrence or harm in current conditions
0 Not at all likely
1
2
3
4
5 Extremely likely
How often has this hazard occurred previously?
Never
Rarely
Sometimes
Often
Always
Who could be affected?
Self
Co-workers
Supervisors or managers
Contractors
Visitors or customers
Public
Not sure
Was any equipment, PPE, or process involved?
Equipment or tool
Vehicle
PPE
Chemical or substance
Procedure or work process
Not applicable or none
Not sure
Actions taken at the time
Is the area currently safe?
Yes
No
Urgency of response needed
Immediate (within 24 hours)
Soon (1-3 days)
Routine (within 2 weeks)
Not sure
Suggested corrective actions or recommendations
Who else has been notified?
Supervisor or manager
Safety or HS team
HR
Facilities or maintenance
Security
Union representative
No one yet
Not sure
Do you want a follow-up about this report?
Yes
No
Best time to contact (optional)
Do you consent to share this report with relevant safety personnel?
Yes
No
Typed signature (full name)
Signature date
I confirm the information provided is accurate to the best of my knowledge
True
False
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Paper art illustration representing workplace safety and concerns form template for FormCreatorAI article

When to use this form

Use this form whenever an employee spots a hazard, unsafe behavior, or a near miss on site or while working remotely. Supervisors, safety leads, and HR benefit by getting clear, trackable reports they can act on. Typical scenarios include a blocked fire exit, a wobbly ladder in the warehouse, a chemical odor in the lab, or a suspicious email targeting staff. Pair submissions with a fire drill review using the Fire drill checklist form. For ongoing culture checks, combine responses with the Occupational health and safety questionnaire form. If the issue involves IT threats, route details to the Cyber security risk assessment checklist form. The outcome is faster fixes, better documentation, and fewer incidents.

Must Ask Workplace Safety and Concerns Questions

  1. What hazard or concern did you observe, and where exactly did it occur?

    Specific hazard and precise location let you triage and route the issue to the right team. It speeds inspection and the right control measures.

  2. When did this happen, and how often have you noticed it?

    Timing and frequency show urgency and trend, helping you prioritize. Recurring problems may need broader fixes, not just a one-off repair.

  3. Who was affected or at risk (employees, contractors, visitors)?

    Identifying who is exposed directs notifications, training, and protective equipment decisions. It also supports compliance records and duty of care.

  4. What immediate actions were taken, and is the area safe right now?

    This reveals current risk and whether temporary controls are in place. It guides whether you need to isolate the area or escalate.

  5. What corrective or preventive measures do you recommend?

    Frontline suggestions often surface practical fixes and needed resources. You can schedule a quick follow-up using a Tailgate safety meeting form to align the team.

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