Title Page

  • Conducted on

  • Prepared by

Report

Details of Worker

  • Date and time hazard identified

  • Location where hazard identified
  • Has a Health and Safety Representative been consulted in relation to this hazard?

  • Name of HSR

  • Date of consultation

Details of Hazard

  • Describe the hazard

  • What are the risks to people or to the environment as a result of this hazard?

  • What are the control measures you would suggest for this hazard?

Risk Assessment

  • Can I add a risk matrix in this section??????????????

Risk Controls

  • List any short term actions that have been implemented to control the hazard.

Control of Hazard

  • Comments

Signature

  • Signature of worker filling out this form

  • Investigation completed by

  • Name

  • Division/Team

  • Position

  • Phone

  • Signature

  • Date

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.