Use this form to report health and safety hazards. Please complete all information as appropriate.
1. Details of the person reporting the hazard
First Name
Last Name
Mobile Number
Email Address
Position
2. Hazard
Brief Description of hazard (Describe the task, equipment, tolls and people involved. Use diagrams if necessary. Include any action to ensure the safety of those who may be affected.)
Where is the hazard located?
What date was the hazard identified?
What time hazard identified?
Recommended action to fix hazard: (List any suggestions you may have for reducing or eliminating the problem - for example update procedures, improve training, maintenance work.)
Date submitted to Core Team (completed this form)
Time submitted to Core Team (completed this form)
3. Action Taken (To be completed by a member of the Core Team)
Has the hazard been acknowledged by the Core Team
Yes
No
Describe what has been done to resolve the hazard
Do you consider the hazard fixed?
Yes
No
Core Team Member Name
Core Team Position
Core Team sign off date
Submit
