H&S Hazard / Risk Report
A HAZARD or RISK is anything that can HARM or HURT you
Date
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Day
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Month
Year
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Name
*
First Name
Last Name
E-mail
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
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Area Code
Phone Number
Tell us about the HAZARD or RISK
What is the HAZARD or RISK you would like to tell us about?
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How do you think we can fix this HAZARD or RISK to make it safer / better?
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Submit HAZARD or RISK
Resolver Action - BTI staff to fill in the following section
Resolver Name
First Name
Last Name
Date
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Day
-
Month
Year
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Hazard/Risk Name
Potential Harm Description:
Any Recommendations
Likelihood of Occurance
Rows
Almost Certain (5)
Highly Likely (4)
Moderate Possibility (3)
Slight Possibility (2)
Rare (1)
Likelihood of Occurance
Potential Consequence
Rows
Fatality (5)
Major Injury (4)
Moderate Injury (3)
Minor Injury (2)
No Injury or Slight Injury (1)
Potential Consequence
Likelihood Score
Potential Consequence Score
RISK RATING SCORE
Likelihood Score + Potential Consequence Score = RISK RATING SCORE
Risk Rating - ACTION REQUIRED
Rows
9-10 EXTREME
7-8 HIGH
5-6 MEDIUM
3-4 MINOR
2 LOW
RISK
Action Taken:
Follow Up Action / Review
No Further Action Required
Review 7 days
Review 1 Month
Review 6 Months
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Submit HAZARD / RISK Control
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