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Hazard Report Form Sample

1) This hazard report form is used to report hazardous situations found at a workplace. 2) It collects details of the hazard, including its location and description, and a risk assessment of the potential injury and likelihood. 3) The form recommends corrective actions to control the hazard, either by eliminating it, substituting safer options, using engineering or administrative controls, or personal protective equipment. It requires follow up to ensure the hazard has been effectively addressed.

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welly1980ok
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281 views

Hazard Report Form Sample

1) This hazard report form is used to report hazardous situations found at a workplace. 2) It collects details of the hazard, including its location and description, and a risk assessment of the potential injury and likelihood. 3) The form recommends corrective actions to control the hazard, either by eliminating it, substituting safer options, using engineering or administrative controls, or personal protective equipment. It requires follow up to ensure the hazard has been effectively addressed.

Uploaded by

welly1980ok
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Hazard Report Form

This form is for reporting hazards, complete this form if you notice a hazardous situation. Rectify the hazard immediately if you are able to do
so and report what action you have taken. If unable to rectify the hazard, state what action you recommend and give this report to <insert title
of person who form goes to>.
1. Details of person reporting hazard
First Name: Family Name:
Centre/Program :
Position: Phone (w): Phone (h or m):
Supervisor/Manager:
q Employee q Contractor /Volunteer q Visitor q Agency Casual
2. Identify the hazard
Date hazard identified: Time hazard identified: am/pm
Location of hazard – if external give the nearest room:
Level: Room: Playground:

Other:

Describe the Hazard:

Why/How is it a Hazard:

3. Assess the Risk


The risk rating of a hazard is based on the combination of likelihood, consequence and amount of exposure to a hazard.

Risk Assessment Matrix


How likely is it to be that serious?
How serious could the injury be?
Very likely Likely Unlikely Very unlikely
Death or permanent disability 1 1 2 3
Long term illness or serious injury 1 2 3 4
Medical attention and several days off 2 3 4 5
First aid needed 3 4 5 6

Severity – is a measure of an injury, illness, incidents, or Likelihood – is defined as the potential that an accident will
disease occurring. When assessing severity, the most happen that may cause injury or harm to a person. When
severe category that would be most reasonably expected making assessment of likelihood, you must establish which
should be selected. of the categories most closely describes the probability of the
hazardous incident occurring.
Consequences Table
1 and 2 Extreme risk; consider elimination of the activity. Otherwise determine controls that are reasonably
practicable to minimise the risk.
3 and 4 Moderate risk; determine controls that are reasonably practicable to minimise the risk.
5 and 6 Low risk; manage by routine procedures.
4. Corrective Action Plan – How do you recommend the hazard is controlled?
Please use the Hierarchy of Controls to complete this corrective action plan, give priority to the hazard being eliminated.
1. Eliminate 2. Substitute 3. Engineering Control 4. Administrative Control 5. Personal Protective Equipment
Actions recommended to be taken By Whom By When

Consultation with work colleagues, management and other affected parties will assist in indentifying effective controls. Do not identify a person
to action an item unless you have spoken with them.

Manager/Supervisor to complete:
5. Have the control measures been implemented?
q YES Date: q NO
Provide comments on action taken to remedy the hazard; or proposed actions

Signature:
Fax/email hazard report form to : 1. <Health & Safety/Compliance Manager/HSR>
Date sent:
2. <Principal/Business Manager>(if applicable)

H&S Committee Comments


Provide comments on action taken to remedy the hazard or proposed actions

<Health & Safety/Compliance Manager/HSR> Comments


Provide comments on action taken to remedy the hazard or proposed actions

Signature:
Is referral to senior management required? q Yes q No Date Referred: To whom:

Office Use only:


<Principal/Business Manager> Follow Up
Has the hazard been controlled effectively? What if any follow up action is required?

Is a follow up risk assessment required? month


q Yes q No If Yes: q 3 q 6 q 12
s
Is entry onto the site Risk Register required? q Yes q No
Actioned by: Date:

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