HAZARD REPORT FORM - SCS

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Time and Date hazard identified:

  Date

Description of hazard

• Type of hazard

  Select Slip Trip Damage Security Safety Other

  • Slip
  • Trip
  • Damage
  • Security
  • Safety
  • Other

• Where is the hazard?

• What is the hazard?

• Add photo of hazard

  Media

• What could happen as a result of the hazard?

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

• Is the risk from the hazard now acceptable?

  Yes

  No

  N/A

Long term recommendations

• Do you recommend any long term solutions or do you have any additional comments

• Who would be responsible to rectify hazard?

Person reporting the hazard

• Signature

  Sign