MSDC Parks & Open Spaces Risk Assessment Form

• Site Name

• Location
  Address

• Conducted on

  Date

• Prepared by

Site Details

• Site Type

  Select Allotment Conservation Site Leisure Park Sportsground Open Space Playground

  • Allotment
  • Conservation Site
  • Leisure Park
  • Sportsground
  • Open Space
  • Playground

Hazards found at this site

• Uneven ground

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Steps and staircases

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Steep Slopes

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Water hazards

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Trees and shrubs

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Equipment

• Equipment type

  Select play equipment sports equipment safety equipment skate/BMX equipment

  • play equipment
  • sports equipment
  • safety equipment
  • skate/BMX equipment

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Buildings and structures

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Street furniture

• Type

  Select benches lighting columns bins fencing/railings signage

  • benches
  • lighting columns
  • bins
  • fencing/railings
  • signage

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Manholes

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Electrical installations

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Surrounding environment

• Description of the hazard

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Other

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

Additional hazards found at the time of inspection

• Are there any additional hazards found at the time of this inspection?

  Yes

  No

• Damage to grassed area

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Damage to trees/shrubs

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Damage to paved area

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Damage to street furniture

• Type

  Select benches lighting columns bins fencing/railings signage

  • benches
  • lighting columns
  • bins
  • fencing/railings
  • signage

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Damage to equipment

• Equipment type

  Select play equipment sports equipment safety equipment skate/BMX equipment

  • play equipment
  • sports equipment
  • safety equipment
  • skate/BMX equipment

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Damage to building(s)

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Hazardous activities

• Type

  Select Anti-social behaviour Dangerous dogs Sports related Unauthorised activity Other

  • Anti-social behaviour
  • Dangerous dogs
  • Sports related
  • Unauthorised activity
  • Other

• Specify

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Environmental hazards

• Type

  Select Noise nuisance Dog fouling Sharps Chemicals Pollution Hazardous waste Other

  • Noise nuisance
  • Dog fouling
  • Sharps
  • Chemicals
  • Pollution
  • Hazardous waste
  • Other

• Specify

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Vehicle movements on site

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Weather related

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

• Other

• Description of the hazard

• Photo of the hazard

  Media

• Associated Risks

  Select Slips, trips and falls Fall from height Crush injuries Cuts Splinters Head injuries Infection Drowning Burns Other

  • Slips, trips and falls
  • Fall from height
  • Crush injuries
  • Cuts
  • Splinters
  • Head injuries
  • Infection
  • Drowning
  • Burns
  • Other

• Please specify

• Risk rating for this hazard

• Likelihood

  1 - Highly Unlikely

  2 - Unlikely

  3 - Possible

  4 - Likely

  5 - Almost Certain

• Severity

  1 - Minor Injury (No 1st Aid)

  2 - Minor Injury (1st Aid)

  3 - Injury - Dr/Hospital Treatment

  4 - Major (life changing) injury

  5 - Fatality

• Likelihood x Severity

• No action required

• Control measures to be considered

• Control measures to be implemented urgently

• By whom:

• By when:

  Date

• IMMEDIATE ACTION REQUIRED

• By whom:

• By when:

  Date

• Precautionary action taken

  Select Reported Removed Repaired Isolated No action required

  • Reported
  • Removed
  • Repaired
  • Isolated
  • No action required

• Reported to: via:

Confirmation

• No other defects found at the time of inspection

• Date and time this inspection was completed

  Date

• Signature of officer completing this form

  Sign