Jesse Greene

MC Hazard Report Form

Use this hazard report form to: - Report a hazard - Describe the hazard using text, images, and annotations - Determine the seriousness of the injury and the medical attention required

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Print as PDF

Use this Template

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Title Page

Date and Time Hazard Identified
Person Reporting Hazard (Optional, but encouraged)
Location of Hazard (Provide details to help us locate. Building, area, etc.)

Describe the Hazard
Why/How is it a Hazard? What could foreseeably happen if the hazard was not addressed.
How urgent is the issue or likelihood that an incident could happen?
What is the severity of a possible incident related to the hazard?
Add a photo of the hazard if possible.
What action is needed to address the hazard? (If known)
Additional Comments

For Supervisor/Manager

Have corrective actions been taken?
Have control measures been implemented?
Hazard Report Form completed on:
Name and Signature:

Jesse Greene

MC Hazard Report Form

Use this hazard report form to: - Report a hazard - Describe the hazard using text, images, and annotations - Determine the seriousness of the injury and the medical attention required

Use this Template

Print as PDF

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.