Hazard Report Form

"*" indicates required fields

This form is to be completed where a hazard has been identified but no incident or injury has occurred. If incident or injury has occurred, please complete the Confidential Incident/Injury Report Form. Ensure that a Hazard Report Form has been completed and is retained as a record of the issue and the outcome and resolution.

Name*

First Last

Date*

Time

Position*

Site Address:*

Job Owner*

Description of hazard/safety issue*

Exact location of the hazard:*

When was the hazard identified?*

Recommended action to ensure safety:*

Recommended action to be completed by and who?*

Signature*