HAZARD IDENTIFICATION FORM - W

• Audit Title

• Document No.

• Client / Department

• Conducted on

  Date

• Prepared by

• Prepared by

• Location
  Address

• Others consulted

Description of hazard

• Type of hazard

  Select Manual Task / ergonomic Electricity Machinery and Equipment Hazardous Chemicals Temperatures / weather effects Noise radiation Biological psychosocial Work design and management Health and Security slip, trips and fall other Fire

  • Manual Task / ergonomic
  • Electricity
  • Machinery and Equipment
  • Hazardous Chemicals
  • Temperatures / weather effects
  • Noise
  • radiation
  • Biological
  • psychosocial
  • Work design and management
  • Health and Security
  • slip, trips and fall
  • other
  • Fire

• Explain the hazard & the context in how the hazard poses a risk

• Add photo of hazard

  Media

Assess the risk

• What would a reasonably foreseeable outcome be if an incident occurred

• Consequence

  1 Low

  2 Minor

  3 Moderate

  4 Major

  5 Catastrophic

• Likelihood

  1 Almost certain

  2 Likely

  3 Possible

  4 Unlikely

  5 Rare

• Risk Rating

  Low

  Medium

  High

  Extreme

• 

Control the hazard

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

• Take a picture of your completed actions

  Media

Long term recommendations

• Do you recommend any long term solutions or do you have any additional comments

• Add drawing

  Drawing

Assess risk after long term recommendations

• Consequences

  1 Low

  2 Minor

  3 Moderate

  4 Major

  5 Catastrophic

• Likelihood

  1 Almost certain

  2 Likely

  3 Possible

  4 Unlikely

  5 Rare

• Risk rating

  Low

  Medium

  High

  Extreme

• 

Person raising hazard sign off

• Please sign and send to your HSR, Supervisor, Safety Advisor or Manager

  Sign

HSR, Supervisor, Safety Advisor or Manager comments

• What follow up action is required in your opinion

• Do you recommend that a formal risk assessment be conducted

  Yes

  No

  N/A

• Add signature

  Sign