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
- 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
-
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