Insurance & Risk Management Forms Campus Safety Hazards Reporting Form

INSURANCE & RISK MANAGEMENT Phone: (818) 677-2079 Fax: (818) 677- 5853 Mail Drop: 8284

It is the intent of California State University, Northridge to maintain a safe and hazard free campus. To do this, we must constantly be aware of conditions in all campus areas that may lead to injuries. We rely on faculty, staff, students and the general public to let us know of these hazards. If you observe or have knowledge of a campus safety hazard, inform your supervisor, Plant Maintenance, Campus Police, the Campus Public Safety Advisory Board or environmental Health & Safety immediately of any situation beyond your ability or authority to correct.
Please use this form to report any hazards you see or to make any suggestions about improving security, health or safety in general at our campus. You may also call EH&S to report an imminently dangerous hazard. (Please print clearly)
I. Person Making Report:
NAME (Last, First, MI):		PHONE:
(If you wish to remain anonymous, understand that we cannot respond directly back to you)
EMPLOYEE #: OR CSUN ID #:		EMAIL:
NAME OF BUILDING, ROAD OR FIELD:
SPECIFIC FLOOR, ROOM, LAB OR LOT:
II. Hazard:
IMMINENT DANGER MODERATE DANGER MINOR DANGER NO DANGER
III. Hazard Exposure:
FIRE FLOOD EXPLOSION INJURY OR ACCIDENT HEALTH HAZARD SAFETY
III. Hazard Description(s): (Please submit as much detail as possible, Use additional sheets as necessary.)
IV. Your recommendation(s) to correct the hazardous situation:
Any faculty member, staff, student or community member may file this report with the Environmental Health and Safety Department at the above address.
Please DO NOT contact me for follow-up.	Please contact me for follow-up.