DEPARTMENT:

AGENCY:

LOCATION:

DATE:

DATE

HAZARD

IMMEDIATE TEMPORARY CONTROL

LONG-TERM SOLUTION

HAZARD DETECTED

PRIORITY

SCHEDULED/DATE COMPLETION

HAZARD NOT CORRECTED AFTER 30 DAYS SEND LOG TO:

OFFICE OF RISK MANAGEMENT, LOSS PREVENTION SECTION

P.O. BOX 91106

BATON ROUGE, LOUISIANA 70821-9106

SAFETY

PAYS

PRIORITY

E = EMERGENCY C = ONE MONTH

A = TODAY D = THREE MONTH

B = ONE WEEK

REVIEWED BY:

DATE:

REVIEWED BY:

DATE: