Description of Hazard

Type of Hazard

Explain the hazard and the context in how the hazard poses a risk

Add media
Assess the risk

What would a reasonable foreseeable outcome be if an incident occurred?



Risk Rating

Control the hazard

Describe what you have done to make the hazard safe!

Add media

What are your recommendation to correct the hazard.

Send report to HSSE Manager,Department Manager, and Supervisor. If it requires a facility maintenance copy to the Facilty Manager.
Select date
Person completing the report
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.