Hazard / Incident Report

Hazard / Incident Report Form

If the hazard or incident requires the attendance of emergency services, please call 000

If there is imminent danger to persons or property, the person recognising the danger must take steps to isolate the danger and restrict access / entry if necessary.
Your Details
Name:
Company:
Date & Time:

DayMonthYearHourMinutesAM/PM Option

Nature of Hazard
Brief description of the hazard:
Describe the task, equipment, and tools involved. Add photos below if necessary.
Photo 1:
Photo 2:
Photo 3:
Please identify who / what is at risk:

Other
Please describe the imaginable consequence of the hazard:

Please identify the severity of the potential risk to persons or property:

	1	2	3	4	5

1 is Mild, 5 is Extreme

Location of Hazard
Where is the hazard located:
Add photos below if necessary to identify the location.
Photo 1:
Photo 2:

Nature of Incident Resulting in Injury
Brief description of the incident that has occurred:
Describe the action or task being undertaken at the time of incident, and the resulting injury. Include photos below if applicable.
Photo 1:
Photo 2:
Photo 3:

Indicate the apparent severity of the sustained injury:

	1	2	3	4	5

1 is Mild, 5 is Extreme

Where did the incident occur:
Add photos below if necessary to identify the location.
Photo 1:
Photo 2:

Nature of Damage to Property
Brief description of the damage that has occurred:
Describe the action or task being undertaken at the time of incident, and the resulting damage. Include photos below if applicable.
Photo 1:
Photo 2:
Photo 3:

Near Miss Incident
Brief description of the incident resulting in a near miss:
Describe the action or task being undertaken at the time of incident. Include photos below if applicable.
Photo 1:
Photo 2:
Photo 3:

Action Required / Taken
Recommended action to eliminate the hazard / avoid a recurrence of the incident:
List any suggestions you may have for reducing or eliminating the problem.
Has this hazard / incident been reported to on-site management?
On-site manager name:
Has action been taken to fix the hazard / avoid a recurrence of the incident?
Please describe the action which has been taken:
Include whether this is a permanent or temporary solution. Upload photos below if necessary.
Photo 1:
Photo 2:

Declaration
I declare that all of the information provided within this form is true and accurate, written in my own words and to the best of my knowledge.
Signature of person completing form:
Should be Empty:

Hazard / Incident Report Form