Information
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Project Name
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Site address
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Conducted on
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Prepared by
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Personnel reporting the hazard, if not the person filling out this form.
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Document No.
Description of hazard
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Type of hazard
- Manual Tasks
- Gravity
- Electricity
- Machinery & Equipment
- Hazardous Chemicals
- Extreme Temperature
- Noise
- Radiation
- Biological
- Pshycosocial
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Explain the hazard & the context in how the hazard poses a risk
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Add photo of hazard
Assess the risk
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What would a reasonably foreseeable outcome be if an incident occurred
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Consequence
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Likelihood
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Risk Rating
Control the hazard
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Describe what you have done to make the hazard safe!
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Take a picture of your completed actions
Long term recommendations
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Do you recommend any long term solutions or do you have any additional comments
Person raising hazard sign off
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Please sign and send to your HSR, Supervisor, Safety Advisor or Manager
HSR, Supervisor, Safety Advisor or Manager comments - if present at time of report.
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What follow up action is required in your opinion
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Do you recommend that a formal risk assessment be conducted
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Add signature