City of Palmesrton - HAZARD IDENTIFICATION FORM - duplicate

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Description of hazard

• Nature of hazard

• Name of employee reporting hazard

• Type of hazard

  Select Manual handling/Ergonomic Environment/Asset Biological and infection Equipment Chemicals Electrical PPE

  • Manual handling/Ergonomic
  • Environment/Asset
  • Biological and infection
  • Equipment
  • Chemicals
  • Electrical
  • PPE

• Details of the identified Hazard/Risk

• Add photo of hazard

  Media

• Location of the hazard (if applicable

Assess the risk

• What would a reasonably foreseeable outcome if an incident occurred

• Consequence

  Insignificant

  Minor

  Moderate

  Major

  Catastrophic

• Likelihood

  Almost Certain

  Likely

  Possible

  Rare

• Risk Rating

  Low

  Medium

  High

  Extreme

Risk Management officer to complete (this point onwards)

• Name of Risk Management Officer

Control the hazard

• Type of control

  Select Eliminate Substitution Isolation Engineering Measures Administrative Measures PPE

  • Eliminate
  • Substitution
  • Isolation
  • Engineering Measures
  • Administrative Measures
  • PPE

• Other type of control

  Select Equipment purchase Reorganise work area Training Procedure development External organization Audit Other

  • Equipment purchase
  • Reorganise work area
  • Training
  • Procedure development
  • External organization
  • Audit
  • Other

• Describe what you have done to make the hazard safe!

• Take a picture

  Media

• Select date

  Date

Follow up actions

• What follow up action is required

Person responsible for follow up

• Who is responsible for follow up action?

• Corrective action complete?

  Yes

  No

  N/A

• Take a picture of completed action

  Media

• If incomplete when will corrective action be completed?

• Date of review

  Date

• Responsible person sign off

  Sign