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:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.