Sommer & Staff Hazard Report Form

• Document No.

GENERAL

• Project Number & Project Name:

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

• Hazard report date

  Date

• Hazard reported to (name and position):

• Responsible company:

  Sommer & Staff

  Conctractor

• Contractor name:

Hazard details:

• Hazard location:

• Add location
  Address

• Work activity:

• Hazard identified in relation to the work activity:

• Hazard evidence (take or upload photo here):

  Media

• Hazard risk rating:

  High (1)

  Medium (2)

  Low(3)

• 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?

  Immediate

  Within 7 days

• Please choose how many days:

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

  Media

Signatures

• Signature of person reporting hazard

  Sign

• Signature of person completing the corrective action:

  Sign

• Completion of corrective action confirmed by

  Sign