Title Page

  • Date and Time Reported

  • Hazard Reported by

  • Contact Number of Person Reporting Hazard

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

Incident / Hazard

Incident Details

  • Incident / Hazard Type

  • If Incident Occurred,

  • Description of Incident / Hazard

Injury Details

  • Only Complete for Incident With Injury

  • Name of Injured Person

  • Contact Number of Injured Person

  • Nature of Injury

  • If Other, please describe injury

  • Location of Injury on Body

  • Specific Task Being Performed at Time of Injury

  • Level of Treatment Needed

  • Name of First Aider or Treatment Provider

  • Description of Treatment Provided

Corrective Actions

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

  • Likelihood

  • Determining Level of Risk

  • 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

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

  • Corrective Actions
  • Control Type

  • Please click "Action" icon below

  • 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.

Final Page

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

  • Signature of Person Reporting Hazard

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.