Incident / Hazard Report Form

• Date and Time Reported

  Date

• Hazard Reported by

• Contact Number of Person Reporting Hazard

• Location of Hazard
  Address

• Specific Location (room or area within the building, compound, or facility)

Incident Details

• Incident / Hazard Type

  Hazard

  Near Miss

  Incident Occurred

• If Incident Occurred,

  Without Injury

  With Injury

• Description of Incident / Hazard

Injury Details

• Only Complete for Incident With Injury

• Name of Injured Person

• Contact Number of Injured Person

• Nature of Injury

  Cut

  Bruising

  Burn

  Other

• If Other, please describe injury

• Location of Injury on Body

• Specific Task Being Performed at Time of Injury

• Level of Treatment Needed

  Report Only

  First Aid

  Medical Treatment

  Lost Time Injury

• Name of First Aider or Treatment Provider

• Description of Treatment Provided

Contributing Factors

• Lack of/Inadequate Equipment/Machinery

• Lack of/Inadequate Procedures/Instructions

• Lack of/Inadequate Management/Supervision

• Lack of/Inadequate Management System

• Lack of/Inadequate Employee/Worker Training

• Inappropriate/Inadequate Work Environment

• Inappropriate Actions and/or Behavior

• Other

• Cause of Incident/Hazard

Risk Assessment

• Consequence

  Minor

  Moderate

  Major

  Severe

• Likelihood

  Unlikely

  Possible

  Likely

  Almost Certain

• Determining Level of Risk

  Select Consequence - Severe, Likelihood - Almost Certain Consequence - Severe, Likelihood - Likely Consequence - Severe, Likelihood - Possible Consequence - Severe, Likelihood - Unlikely Consequence - Major, Likelihood - Almost Certain Consequence - Major, Likelihood - Likely Consequence - Major, Likelihood - Possible Consequence - Major, Likelihood - Unlikely Consequence - Moderate, Likelihood - Almost Certain Consequence - Moderate, Likelihood - Likely Consequence - Moderate, Likelihood - Possible Consequence - Moderate, Likelihood - Unlikely Consequence - Minor, Likelihood - Almost Certain Consequence - Minor, Likelihood - Likely Consequence - Minor, Likelihood - Possible Consequence - Minor, Likelihood - Unlikely

  • Consequence - Severe, Likelihood - Almost Certain
  • Consequence - Severe, Likelihood - Likely
  • Consequence - Severe, Likelihood - Possible
  • Consequence - Severe, Likelihood - Unlikely
  • Consequence - Major, Likelihood - Almost Certain
  • Consequence - Major, Likelihood - Likely
  • Consequence - Major, Likelihood - Possible
  • Consequence - Major, Likelihood - Unlikely
  • Consequence - Moderate, Likelihood - Almost Certain
  • Consequence - Moderate, Likelihood - Likely
  • Consequence - Moderate, Likelihood - Possible
  • Consequence - Moderate, Likelihood - Unlikely
  • Consequence - Minor, Likelihood - Almost Certain
  • Consequence - Minor, Likelihood - Likely
  • Consequence - Minor, Likelihood - Possible
  • Consequence - Minor, Likelihood - Unlikely

• If Option Selected Previously is Red, Level of Risk is High.

• If Option Selected Previously is Yellow, Level of Risk is Medium.

• If Option Selected Previously is Green, Level of Risk is Low.

• Level of Risk

  High

  Medium

  Low

• If Level of Risk is High or Medium, at least 1 corrective action must be completed.

Corrective Actions

• Control Type

  Elimination/Removal

  Substitution/Replacement

  Isolation/Stop Use

  Fixing/Repairing

• Please click "Action" icon below

  Corrective Action Created

  Corrective Action Not Created

  No Need for Corrective Action

• After creating an action, set the date and time the corrective action has to be completed and assign it to a user in your organization.

• To whom should this hazard report form be sent to?

• Signature of Person Reporting Hazard

  Sign