Information
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Document No.
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Client/Witness
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Conducted on
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Prepared by
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Location
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Personnel
Description of hazard
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Nature of hazard/dumped materials located
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Contact details of person reporting hazard
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Type of hazard/dumped materials
- Manual handling/Ergonomic
- Environment/Asset
- Biological and infection
- Equipment
- Chemicals
- Electrical
- PPE
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Details of the identified Hazard/dumped materials including any identifiable materials located.
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Add photo of hazard
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Location of the hazard/materials located
Assess the risk
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What would be a reasonably foreseeable outcome if the materials were left insitu?
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Consequence
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Likelihood
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Risk Rating
Risk Management officer to complete (this point onwards)
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Name of Investigating Officer
Control the hazard/materials
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Type of control
- Eliminate
- Substitution
- Isolation
- Engineering Measures
- Administrative Measures
- PPE
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Other type of control
- Equipment purchase
- Reorganise work area
- Training
- Procedure development
- External organization
- Audit
- Other
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Describe actions undertaken to clean up the site and to locate possible offender.
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Take a picture
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Select date
Follow up actions
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What follow up action is required
Person responsible for follow up
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Who is responsible for follow up action?
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Corrective action complete?
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Take a picture of completed action
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If incomplete when will corrective action be completed?
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Date of review
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Responsible person sign off