Title Page
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Conducted on
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Prepared by
Report
Details of Worker
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Date and time hazard identified
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Location where hazard identified
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Has a Health and Safety Representative been consulted in relation to this hazard?
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Name of HSR
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Date of consultation
Details of Hazard
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Describe the hazard
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What are the risks to people or to the environment as a result of this hazard?
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What are the control measures you would suggest for this hazard?
Risk Assessment
Risk Controls
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List any short term actions that have been implemented to control the hazard.
Control of Hazard
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Comments
Signature
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Signature of worker filling out this form
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Investigation completed by
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Name
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Division/Team
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Position
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Phone
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Signature
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Date