WWCC - Hazard Reporting Form

• Conducted on

  Date

• Prepared by

Details of Worker

• Date and time hazard identified

  Date
• Location where hazard identified
  Address

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

  Yes

  No

• Name of HSR

• Date of consultation

  Date

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

  Sign

• Investigation completed by

  Team Leader

  Supervisor

  Manager

• Name

• Division/Team

• Position

• Phone

• Signature

  Sign

• Date

  Date