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Health and Safety Initiation Form
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Name
Your answer
Date
MM
/
DD
/
YYYY
Would you consider this a health related problem?
Yes
No
Clear selection
If yes, please check all that apply:
Odor
Temperature/Humidity
Headache, lethargy, nausea, drowsiness, dizziness
Swelling, itching, or irritated eyes, nose or throat, congestion
Cough, chest tightness, shortness of breath, fever or chills, and/or fatigue
Would you consider this a safety related problem?
Yes
No
Clear selection
Please describe:
Your answer
Location/Room number
Your answer
Ongoing Problem?
Yes
No
Clear selection
Occurence dates/times:
Your answer
Other:
Your answer
Submit
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