Hazard Notification Form

• Document No.

• Audit Title

• Client / Site

• Prepared by

• Position

• Conducted on

  Date

Hazard Details

Exact Location of Hazard

Essentials Category

• Select 1. Working in and around Live Traffic 2. Electrical Work 3. Working at Heights 4. Working in and around Mobile Plant 5. Working with Temporary Works 6. Mechanical Lifting 7. Working with Live Services Not Applicable

  • 1. Working in and around Live Traffic
  • 2. Electrical Work
  • 3. Working at Heights
  • 4. Working in and around Mobile Plant
  • 5. Working with Temporary Works
  • 6. Mechanical Lifting
  • 7. Working with Live Services
  • Not Applicable

Hazard Classification

• Environmental

  Personal Damage

  Plant / Equipment

Hazard Category

• Environmental

  Select Air / Dust / Odour Erosion / Sediment Flora and Fauna Heritage - Indigenous/Non Indigenous Land Noise and Vibration Waste Water Contamination

  • Air / Dust / Odour
  • Erosion / Sediment
  • Flora and Fauna
  • Heritage - Indigenous/Non Indigenous
  • Land
  • Noise and Vibration
  • Waste
  • Water Contamination

• Personal Damage

  Select Human Gravitational Vehicular Machine Object Electrical Thermal Chemical Radiation Noise Other

  • Human
  • Gravitational
  • Vehicular
  • Machine
  • Object
  • Electrical
  • Thermal
  • Chemical
  • Radiation
  • Noise
  • Other

• Plant and Equipment

  Damage

  Electrical

  Guarding

  Other

  Vehicle

• Description of damaging energy.

• Photograph of Hazard

  Media

Details of Action Taken

• Is the area safe now?

  yes

  no

Further action(s) required

Sign off on report

• Add signature

  Sign