Title Page
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Site
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Date
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Reported by
Description of Hazard
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Add the witnessed hazard(s) and details as required below
Hazard Details
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Hazard Detail
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Hazard Description
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Assess the hazard, and assign the potential impact of this hazard
- Catastrophic - Potential death, permanent disability, catastrophic structural damage
- Major- Injury or illness requiring immediate emergency response, permanent disability or major structural failure/damage
- Moderate - Incident or injury requiring medical treatment within 48 hours of exposure
- Minor - Incident that has the potential to require first aid. On-site environment
- Insignificant - Incident resulting in no injury or illness which would need first air or medical treatment
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Assess the likelihood of this hazard harming yourself or others
- Almost Certain - The event is expected to occur in most circumstances
- Likely - The event will probably occur at some time
- Possible - The event may occur at some time
- Unlikely - The event is unlikely to occur
- Rare - The event will occur only in exceptional circumstances
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Control Plan
- Elimination
- Subsitution
- Isolation
- Minimise: Engineering Controls
- Minimise: Administration Controls
- Minimise: Personal Protective Equipment
Photos of Hazard
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Please provide photos of the hazard before the controls are implemented
Control Plan
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Control Plan Assignee
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Was the control implemented while you were still on site?
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Why was the control not implemented while you were on site?
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Status while controls haven't been implemented
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When will it be implemented?
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Who will be implementing it?
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Follow up due
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Please provide photos of the hazard after the controls are implemented
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Status after controls are implemented
Signature
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Signature
