Hazard Reporting Form - Southern Safety SolutioNZ

• Project Name

• Site address

• Conducted on

  Date

• Prepared by

• Personnel reporting the hazard, if not the person filling out this form.

• Document No.

Description of hazard

• Explain the hazard & the context in how the hazard poses a risk

• Add photo of hazard

  Media

Assess the risk

• What would a reasonably foreseeable outcome be if an incident occurred

  Low

  Medium

  High

  Extreme

• Consequence

  1 Low

  2 Minor

  3 Moderate

  4 Major

  5 Catastrophic

• Likelihood

  A Almost Certain

  B Likely

  C Possible

  D Unlikely

  E Rare

• Risk Rating

  Low

  Medium

  High

  Extreme

Control the hazard

• Describe what you have done to make the hazard safe!

• Take a picture of your completed actions

  Media

Long term recommendations

• Do you recommend any long term solutions or do you have any additional comments

Person raising hazard sign off

• Please sign and send to your HSR, Supervisor, Safety Advisor or Manager

  Sign

HSR, Supervisor, Safety Advisor or Manager comments - if present at time of report.

• What follow up action is required in your opinion

• Do you recommend that a formal risk assessment be conducted

  Yes

  No

  N/A

• Add signature

  Sign