Safety report worksheet
A printable from Report unsafe conditions at work. Fill it in by hand. Nothing you write is collected by this website.
Safety report worksheet
The danger
- What it is, in plain words
- Exactly where it is (building, floor, area, machine)
- Since when, and how often it happens
- Who is exposed, and how many people
- Anyone hurt or sick so far (no names needed)
The workplace
- Business name, as on a pay stub or sign
- Worksite address and zip code
- Supervisor's name
What I already did
- Told a supervisor? Date and what they said
- Photos or messages saved at home or on my own phone
My report
- Date I called or emailed Cal/OSHA, and which office
- Name of the person I spoke with
- Whether I left my contact information
If I am punished
- Date and what happened (fired, hours cut, threats)
- Who saw it
- Retaliation complaint filed on: ________ (within 1 year)
From Report unsafe conditions at work. Facts checked October 21, 2026. Free information, not legal or medical advice.