Title Page

  • Name of Organization

  • Copy No.

  • Conducted on

  • Prepared by


Hazard Identification

  • Describe Hazard

  • Hazardous Condition

  • Unsafe Behavior

  • Possible Accident Types

  • Please specify

  • Risk probability

  • Risk severity

Recommended Corrective Action(s)

  • Engineering controls

  • Management controls

  • Personal Protective Equipment

Recommended System Improvement(s)

  • Specify recommended improvement(s)

Determination of Legal and other Requirements

  • Name of regulation/requirement

  • Reference #

  • Area of the organization it impacts

  • Interested parties

  • Document stipulating the requirement/compliance obligation

  • Responsible Person

  • Source of information (can be indicated in a hyperlink or description format)

Objective Planning

  • What is to be done?

  • Resources required (e.g., financial, human, equipment & infrastructure)

  • Responsible person

  • Target date of completion

  • Metrics for evaluation & indicators for monitoring

  • Priority Level


  • Approved by

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.