Report type

Report Type

Description of Hazard

Description of Hazard and how it poses a risk ( or positive observation)

Photos of Hazard / Observation
Assessment of Risk (Not applicable for positive observation

Reasonable foreseeable outcome be if an incident occurred



Risk Rating

Control the hazard

Corrective Action

Describe actions ( If applicable)

Photos of corrective action
Long term recommendations

Describe recommendations

Name and signature of issuer
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.