Safety Submission Form

One of the most important steps in any job is to identify the associated potential hazards. Hazards can exist in many forms; they can be visible or hidden, a condition or an act. Recognition and Control of hazards is necessary to ensure that corrective actions are completed on a timely basis.

Employees are expected to participate in Paragon’s proactive reporting program. It’s important for employees to report hazards identified in the workplace and share how they were controlled. All submissions are tracked in order to share commonalities among Paragon worksites.

Complete this form to share your observations and get recognized in the process! Each month, Paragon will award two Paragon employees for their safety submission (80% company-wide participation is required).

Definitions:
Hazard ID: Unsafe acts and conditions that could result in a personal injury or a process upset.
Near Miss: Any event that in different circumstances could have resulted in harm to people, damage to property or loss to a process.
Intervention: is an action or process done in order to keep something from happening.
Positive Safety Observation: is to include positive feedback on someone or something being observed.
Safety Share: is something that you would like to share with your fellow co-workers, relatable to Health, Safety and Wellness. 
 

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* 1. Who is completing this report?

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* 2. What is being reported?

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* 3. When did this happen?

Date

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* 4. Where did this happen?*

*If this is a personal or OH item:
Owner-Client: NA or Paragon (if OH)
Location / site location: City/Intersection/etc. or Paragon Office (if OH; 14805 or 14830)
Project number: NA
Supervisor: NA

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* 5. Describe the action.

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* 6. What was done to eliminate, mitigate or correct?

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* 8. Was anyone else involved?

T