Title Page
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Date and Time Hazard Identified
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Person Reporting Hazard
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Location of Hazard
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Have you notified your supervisor/manager?
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Describe the Hazard
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Why/How is it a Hazard?
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How serious could the injury be?
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How likely is it to be that serious?
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If requiring first aid is very likely or likely, determine controls that are reasonably practicable to minimize the risk. Eliminate hazard if:
-serious injury is very likely or likely
-long term illness is very likely or likely
-permanent disability is very likely, likely, or unlikely
Corrective Action
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Please click "Action" icon below
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After creating an action, set the date and time the action has to be completed and assign it to a user.
For Supervisor/Manager
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Have corrective actions been taken?
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Have control measures been implemented?
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Hazard Report Form completed on:
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Name and Signature:
