# HEALTH CONCERN / SAFETY HAZARD / CHEMICAL SPILL REPORT FORM

SUGGESTED CORRECTIVE ACTION or ACTION ALREADY TAKEN

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| Type | PDF |
| Size | 113 KB |

[Open original PDF →](https://www.northerncollege.ca/uploads/2025/07/HSE-Hazard-Report-Form.pdf)

Referenced from: [Emergency Procedures & Lockdown](/pages/campus-safety/emergency-procedures/)

## Document text

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## HEALTH CONCERN / SAFETY HAZARD / CHEMICAL SPILL REPORT FORM

## CHECK APPROPRIATE CONCERN:

- [ ] HEALTH CONCERN

- [ ] SAFETY HAZARD

- [ ] CHEMICAL SPILL

- [ ] Immediate

- [ ] Immediate

- [ ] Immediate

- [ ] Probable

- [ ] Probable

- [ ] Probable

NAME: (Optional)

DATE:

CAMPUS:

LOCATION / ROOM NO.

DETAILS:

SUGGESTED CORRECTIVE ACTION or ACTION ALREADY TAKEN

## IF CHEMICAL SPILL:

Is area sealed off?

- [ ] YES NO

Is the chemical known

- [ ] YES NO

Name of chemical if known:

NOTE: Never handle chemicals for which you have not been trained. You must use proper personal protective equipment.

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<small>Source: [https://www.northerncollege.ca/uploads/2025/07/HSE-Hazard-Report-Form.pdf](https://www.northerncollege.ca/uploads/2025/07/HSE-Hazard-Report-Form.pdf)</small>