HR Health and Safety Consultation Form

HR HEALTH AND SAFETY CONSULTATION FORM

Use this form to document a workplace health or safety concern, incident, near miss, or consultation between the employee and the employer's health and safety representative. Information provided will be used to assess risk, implement controls, and follow up on corrective actions. Confidentiality will be maintained to the extent permitted by law; however, factual information may be disclosed to relevant supervisors, safety personnel, or investigators as required.

Personal Information

Phone:    Email:

Position Information

Reporting Manager:    Start Date with Employer:

Full-time    Part-time    Contractor    Temporary

Incident / Concern Details

Date of Incident / Concern:    Time:

Hazard    Near miss    Injury    Occupational illness    Safety concern

Immediate Action Taken

Was equipment or area secured?   Yes    No

Was medical attention required?   Yes    No

Preliminary Risk Assessment & Recommendations

Likelihood (describe):    Severity (describe):

Target date for completion:

Follow-up & Outcome

Follow-up completion date:    Issue closed?   Yes    No

Employment History (Most Recent)

Employment History (Previous)

Education

Professional References

Legal Disclosures and Authorization

At-Will Employment: Nothing in this form changes the at-will nature of employment unless an explicit, written agreement signed by authorized representatives of the employer states otherwise.

Equal Opportunity: The employer provides equal employment opportunity without regard to protected characteristics. Reports of health and safety concerns will be considered without discrimination.

Confidentiality & Non-Retaliation: The employer will maintain confidentiality of investigative records to the extent practicable. Retaliation against an individual for reporting a safety concern in good faith is prohibited and may result in disciplinary action.

By checking the boxes below, the employee authorizes the employer to investigate this report, interview witnesses, review relevant records, and, where applicable, contact prior employers for verification of employment and safety history.

I authorize investigation of this report and the collection of relevant information.

I authorize the employer to contact previous employers for verification of employment and safety-related information.

I authorize background checks if required as part of the safety investigation, subject to applicable law.

Applicant Certification

I certify that the information provided in this Health and Safety Consultation Form is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false or misleading information may subject me to disciplinary action, up to and including termination. I acknowledge that submission of this form does not by itself determine final disposition of any investigation or corrective measures.

I acknowledge that I have read and understand the above statements and that I have been given an opportunity to provide relevant documentation or evidence in support of this report.

Sign Now