Hazard Report Form

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

• Audit Title

• Document No.

HAZARD REPORT

• Hazard Description

• Add media

  Media

• Please sketch diagram if required

  Drawing

• Name of person reporting the hazard:

  Sign

• Enter Position

  Select Project Manager Project Superintendent Safety Manager Safety Advisor Engineer Supervisor Leading Hand Employee Contractor

  • Project Manager
  • Project Superintendent
  • Safety Manager
  • Safety Advisor
  • Engineer
  • Supervisor
  • Leading Hand
  • Employee
  • Contractor

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

• Likelyhood

  A Almost Certain

  B Likely

  C Possible

  D Unlikely

  E Rare

• Risk Rating

  Low

  Medium

  High

  Extreme

CONTROL THE RISK

• Has the hazard been controlled?

  Yes

  No

  N/A

• Further action taken / Learning shared:

• Name of Person Reporting the Event:

  Sign

• Enter Position

  Select Project Manager Project Superintendent Safety Manager Safety Advisor Engineer Supervisor Leading Hand Employee Contractor

  • Project Manager
  • Project Superintendent
  • Safety Manager
  • Safety Advisor
  • Engineer
  • Supervisor
  • Leading Hand
  • Employee
  • Contractor

APPROVAL / MANAGEMENT REVIEW:

• Manager to review & approve, or send ffor further investigation:

  Approved

  Further Investigation Required

• Additional actions and Learning shared:

• Management Approval:

  Sign

• Distribution: (1) Project Manager (2) ZH Administrator (3) Zero Harm Advisor