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:

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.