Hazard Report Form

• Document No.

• Conducted on

  Date

• What site is the hazard related to?

• Prepared by

  Select
• Location
  Address

• Personnel

  Select

• site

  Select

Description of hazard

• Explain the hazard & how the hazard poses a risk

• Who will you notify about this hazard?

  Select

• Add photo of hazard

  Media

Assess the risk

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

• Choose the level of Consequences

  Select

• Choose the level of Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• What is the 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?

  Yes

  No

Person raising hazard sign off

• Sign

  Sign

Supervisor or Manager comments

• What follow up action is required in your opinion?

• Do you recommend that a formal risk assessment be conducted

  Yes

  No

• Add signature

  Sign