Hazard Recognition Report

• Hazard Recognition Report

• Cooperative name

• Date and time the hazard was identified and documneted

  Date

• Prepared by

• Location
  Address

• Everyone in the workplace shares the responsibility for ensuring that their work environment is safe and healthy. Once a hazard is identified, assess the problem and eliminate any hazard that could harm employees or the public. Prioritize the hazard as a Priority 1,2 or 3 as defined below.

• Priority #1 - IMMEDIATE DANGER to the public or employees. Repair immediately or within 24 hours (guard, isolate or de-energize).

• Priority #2 - Doesn't present immediate hazardous conditions. Repair within 2-4 weeks. Monitor the situation so it doesn't deteriorate into a Priority #1.

• Priority #3 - Doesn't present immediate hazardous conditions. May require rebuilding. Repair or replace within 4-6 weeks.

• Fill out the information below in regard the hazard you have identified:

• Map location (if needed. Address is identified on Cover page)

• Priority of the hazard

  Select Priority #1 Priority #2 Priority #3

  • Priority #1
  • Priority #2
  • Priority #3

Conductor Clearance

• Primary low

• Secondary Low

• Primary Broke

• Secondary Broke

• Other (identify the hazard )

• Identify "Other"

• Picture(s) of Hazard

  Media

Guy Wire

• Broke

• Loose

• Missing

• Requires Marker (no marker in place or faded and needs replacing)

• Other (identify hazard)

• Identify "Other"

• Picture(s) of Hazard

  Media

Apparatus

• Broken Insulator

• Broken Bells

• Arrestors

• Switches (including cut out)

• Cross Arm

• Braces

• Insulator Pin

• Other (identify other)

• Identify "Other"

• Picture(s) of Hazard

  Media

Pole

• Vegetation (issue with tree's and or vines etc.)

• Leaning

• Broken or split/cracked

• Woodpecker Damage

• Rotten

• Burned (due to lightning or other)

• Other (identify other)

• Identify "Other"

• Picture(s) of Hazard

  Media

Transformer, Regulator, Breaker or Cabinet

• Select Transformer Regulator Breaker Cabinet

  • Transformer
  • Regulator
  • Breaker
  • Cabinet

• Overhead

• Underground

• Single Phase

• 2 Phase

• 3 Phase

• Transformer KVA

• Transformer Voltage

• Grounding issues

• Leaking

• PCB Contaminated

• Non Compliant Signage

• Non Compliant Lock (no dual locking mechanism etc.)

• Rusted or Hole

• Knocked Off Pad/Base

• Other (identify other)

• Identify "Other"

• Picture(s) of Hazard

  Media

Hazard Description

• Enter a Brief Description of the problem(s) Identified Above:

Name and Signature of Person Creating Report

• Name of Person Creating Report

• Signature of Person Creating Report

  Sign

Report Submittal

• Department Report Submitted to:

  Select Operations Engineering Safety Administration Corrected Hazard Upon Identification Other

  • Operations
  • Engineering
  • Safety
  • Administration
  • Corrected Hazard Upon Identification
  • Other

• Identify Specific Person in This Department (if necessary)

Corrective Action

• The Hazard(s) identified in this report were corrected:

  Select Immediately Within 24 Hours Within 2-4 Weeks Within 4-6 Weeks

  • Immediately
  • Within 24 Hours
  • Within 2-4 Weeks
  • Within 4-6 Weeks

• Date and Time of Corrective Action

  Date

• Name of Person Verifying Corrective Action Took Place

• Signature of This Person

  Sign

• Picture(s) of Corrected Hazard

  Media