Hazard Report

This form is to be used if a hazard has been identified but no injury or incident has occured. If there has been an injury, please complete the Incident/Injury/Near Miss Report Form.

Definition:

Hazard: Any condition that exists on the property or within a program that has the potential, if left unchanged, to cause personal injury or damage to the property.

Reported By:

Please provide contact details for the person making the report.

First Name

Last Name

Email Address

Mobile Number

Hazard Details:

Location of Hazard

Tip: Please provide as much detail as possible for the location of the hazard.

Describe hazard identified:

Describe any prevention actions currently taken

Describe any suggestions to remove the hazard

Declaration

By printing my name I declare the information provided above is true and correct.

Name

Date