Title Page
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Name of worker
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Business Name
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Conducted on
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Site Location
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Elderton Manager/Supervisor
- Location & Type Of Hazard
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Location Of Hazard
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Type Of Hazard
- SLIP/TRIP/FALL
- MANUAL HANDLING
- FALLING OBJECTS
- SECURITY
- TOOLS
- WORKING AT HEIGHTS
- NOISE
- ENVIRONMENTAL
- PEDESTRIANS
- LADDERS
- UNDERGROUND SERVICES
- LIGHTING
- WORKING ALONE
- EXPOSED HOLES
- SHARPS/NEEDLES
- BURNS
- HIT BY MOVING OBJECT
- CAUGHT IN/BETWEEN
- DROPPED OBJECTS
- HOT WORKS
- INHALATION
- ASBESTOS
- CONFINED SPACE
- COLD/HOT OBJECTS
- WASTE MANAGEMENT
- VEHICLES
- ELECTRICAL
- MOVING EQUIPMENT
- LIFTING EQUIPMENT
- OVERHEAD POWERLINES
- DAMAGE TO EQUIPMENT
- PSYCHOLOGICAL
- EXPOSURE GAS/HEAT/FUMES
- EXPOSURE DUST/CHEMICALS
- OTHER
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Photo Of Hazard
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Likelihood Of Incident
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Consequence If Hazard Results In Injury
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Description Of Hazard
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Immediate Actions Taken
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Suggestions For Improvements
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Name / Signature
