Hazard Report Form Example
Example document for Hazard Report Form. Use this as a reference when creating your own.
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Document: Hazard Report Form
Example Document
Last updated 7/27/2026
HAZARD REPORT FORM
| Field | Details |
|---|---|
| Report Date | 12/10/2023 |
| Time | 08:15 AM |
| Reporter Name | John Smith |
| Job Title | Electrician |
| Worksite / Location | 123 Collins Street, Level 2 Fit-out |
| Exact Location of Hazard | Corridor B, near the junction box on the ceiling |
Hazard Description
Type of Hazard (Tick all that apply)
[X] Electrical (Exposed wires, faulty equipment) [ ] Physical [ ] Chemical [ ] Biological [ ] Psychosocial [ ] Manual Handling [ ] Other:
Describe the Hazard clearly:
I was installing a light fitting in Corridor B and noticed the ceiling cavity has exposed copper wiring from the old tenancy. The insulation is frayed and the wires are hanging loose near the metal framing. They appear to be live as the adjacent circuit is active.
Risk Assessment
Could this hazard cause serious injury or death right now?
[X] YES (Stop work and notify supervisor immediately) [ ] NO
What could happen if this is not fixed?
If the live wires touch the metal framing or a worker touches them while drilling, it could result in electric shock or electrocution.
Suggested Action
What do you think should be done to fix this?
Isolate the power supply to the old circuit immediately. Tag the switchboard to prevent re-energising. Have a licensed electrician remove or terminate the cables safely before work continues.
Management Response
To be completed by Supervisor or Manager
Action Taken / Recommended:
Power isolated to main board Circuit 4 at 08:30 AM. Lock-out tag-out applied. Master Electrician (Mike Jones) contacted to terminate cables. Work in Corridor B suspended until clearance given.
Priority Level: [X] Immediate (Stop work) [ ] High [ ] Medium [ ] Low
Actioned By: Sarah Jenkins Date: 12/10/2023 Signature: S.Jenkins
Notes
Notes:
- Specificity: The reporter provided the exact corridor and the nature of the wiring.
- Urgency: The reporter correctly identified the risk of electrocution and marked the 'Immediate' danger checkbox.
- Response: Management followed the hierarchy of controls by isolating the energy source first.
- Terminology: The use of 'Lock-out tag-out' shows compliance with electrical safety standards.
About this Example
Part of the Hazard Report Form document collection
Document Type
Hazard Report Form
A standard document used by workers to identify and report workplace health and safety risks to management.