Safety Report

Safety Report
Instructions:

The Safety Report is intended as a mechanism for any United Rotorcraft Team Member to report safety risks or hazards that are found while working. If you notice any situation or physical condition that may result in an accident or injury to you or another Team Member, please fill out the form below.
Observed by: (optional)

First NameLast Name
I'm submitting this report on behalf of someone else
Report submitted on behalf of

First NameLast Name
I wish this safety report to remain

AnonymousConfidential
You have selected to remain anonymous. Please understand by doing so, we will not be able to provide feedback or contact you if more information is needed, and you will not receive any status updates.
You have selected to keep your name confidential on this report. Your name will not be shared with anyone outside the team needed to remedy the reported issue.
Why do you want to remain anonymous/confidential?

Fear of retailiationMy supervisor/manager was notified and nothing has been doneOther
Base Location*

DenverMesaWest Mifflin
Hazard Location - Denver*
Hazard Location - Mesa*
Hazard Location - West Mifflin*
Hazard Location
Observation Type*

Near MissSafe ActUnsafe ActUnsafe ConditionProperty DamageOther
Type of Hazard*

Slip, Trip, or FallElectricalStruck byCaught betweenNo HazardHealth ConcernErgonomicsOther
Does the issue or concern involve an aircraft?*

YesNo
Date of Observation*

MonthDayYear
Date
Approximate Time of Observation/Occurrence*

Hour Minutes

AM/PM Option
Observation details*
File Upload

Cancelof
Was Stop Work Authority used?*

YesNo
Were the hazard(s) corrected?*

YesNo
Date hazard was corrected*

MonthDayYear
Date
Corrective action taken?*
Reported To?*
Assigned to:
example@example.com
Safety Report Number
United Rotorcraft Form F100-EHS-14
Calculation
Should be Empty: