Title Page

  • Document No.

GENERAL

  • Project Number & Project Name:

  • Hazard report number: (project number - hazard report number. E.g.4665-001)

  • Hazard report date

  • Hazard reported to (name and position):

  • Responsible company:

  • Contractor name:

Hazard details:

  • Hazard location:

  • Add location
  • Work activity:

  • Hazard identified in relation to the work activity:

  • Hazard evidence (take or upload photo here):

  • Hazard risk rating:

  • An Non-Conformance report (NCR) must be issued for all high risk hazards, where the corrective action cannot be undertaken immediately.

  • NCR Number

  • NCR issue date:

  • NCR issued by (name and title):

Corrective actions details:

  • Corrective action required:

  • Corrective action to be undertaken by (company and responsible person name):

  • Within how many days should the hazard be attended to?

  • Please choose how many days:

  • Corrective Action Evidence ( take or upload photo here):

Signatures

  • Signature of person reporting hazard

  • Signature of person completing the corrective action:

  • Completion of corrective action confirmed by

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