HAZARD REPORT (Form-1029)
A hazard is a thing or situation which presents the potential to harm a person or property. DO NOT use this form to report an incident, injury or near-miss - please use the Incident Report Form.
Name of person submitting this report:
First Name
Last Name
Phone number:
Date and time hazard identified:
*
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of hazard:
*
E.g. street address, room name or number, indoor/outdoor area
Description of hazard:
*
Take photo of hazard:
Upload photo of hazard:
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*If available
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of
MANAGER USE ONLY
CORRECTIVE ACTION
Using the Risk Matrix below, please determine the level of risk:
Very High
High
Medium
Low
Corrective Action required:
*Please list multiple if needed
Person responsible for Corrective Action:
First Name
Last Name
Date Corrective Action DUE:
-
Day
-
Month
Year
Date
Date Corrective Action COMPLETED:
-
Day
-
Month
Year
Date
Report Now!
Should be Empty: