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.

1. Details of person reporting hazard

2. Identify the 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 serious could the injury be?

Death or permanent disability

Very Likely 1 Likely 1 Unlikely 2 Very Unlikely 3

Long term illness or serious injury

Very Likely 1 Likely 2 Unlikely 3 Very Unlikely 4

Medical attention and several days off

Very Likely 2 Likely 3 Unlikely 4 Very Unlikely 5

First aid needed

Very Likely 3 Likely 4 Unlikely 5 Very Unlikely 6

Severity – is a measure of an injury, illness, incidents, or disease occurring. When assessing severity, the most severe category that would be most reasonably expected should be selected.

Likelihood – is defined as the potential that an accident will happen that may cause injury or harm to a person. When making assessment of likelihood, you must establish which of the categories most closely describes the probability of the hazardous incident occurring.

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

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

5.Manager/Supervisor to complete:

Office Use only:

CEO Follow Up