HAZARD REPORT FORM

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Description of hazard

• Type of hazard

  Select Manual Tasks Gravity Electricity Machinery & Equipment Hazardous Chemicals Extreme Temperature Noise Radiation Biological Pshycosocial

  • Manual Tasks
  • Gravity
  • Electricity
  • Machinery & Equipment
  • Hazardous Chemicals
  • Extreme Temperature
  • Noise
  • Radiation
  • Biological
  • Pshycosocial

• 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

  A Almost Certain

  B Likely

  C Possible

  D Unlikely

  E 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

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