Use this hazard report form to:
- Keep track of when and where the hazard was reported
- Describe the hazard using text, images, and annotations
- Determine the seriousness of the injury and the medical attention required
- Create a corrective action plan to minimize hazard risk
- Implement control measures for accident prevention
Scan this QR code to use this paper checklist on your smartphone or tablet or
visit
https://safetyculture.com/
Title Page
Date and Time Hazard Identified
Person Reporting Hazard
Location of Hazard
Have you notified your supervisor/manager?
Describe the Hazard
Why/How is it a Hazard?
How serious could the injury be?
How likely is it to be that serious?
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
Please click "Action" icon below
After creating an action, set the date and time the action has to be completed and assign it to a user.
For Supervisor/Manager
Have corrective actions been taken?
Have control measures been implemented?
Hazard Report Form completed on:
Name and Signature:
SafetyCulture Staff
Hazard Report Form
Use this hazard report form to:
- Keep track of when and where the hazard was reported
- Describe the hazard using text, images, and annotations
- Determine the seriousness of the injury and the medical attention required
- Create a corrective action plan to minimize hazard risk
- Implement control measures for accident prevention
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions.
The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice.
You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction.
You should independently determine whether the template is suitable for your circumstances.
