HAZARD REPORT FORM

Instructions: Complete this form if you identify any hazard, risk, or unsafe condition in the workplace. Return this form to your supervisor or the WHS Officer immediately. Do not put yourself in danger to gather information.

Field	Details
Report Date	[DD/MM/YYYY]
Time	[HH:MM AM/PM]
Reporter Name	[Full Name of person reporting]
Job Title	[Your Job Title]
Worksite / Location	[Specific site address, building name, or department]
Exact Location of Hazard	[Be specific, e.g., North entry stairwell, Bay 4, Near the compressor]

Hazard Description

Type of Hazard (Tick all that apply)

[ ] Physical (Slip, trip, fall, noise, vibration) [ ] Electrical (Exposed wires, faulty equipment) [ ] Chemical (Spill, fumes, dust, asbestos) [ ] Biological (Mould, bacteria, sharps) [ ] Psychosocial (Bullying, fatigue, stress) [ ] Manual Handling (Heavy lifting, repetitive movement) [ ] Other: [Specify]

Describe the Hazard clearly:

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[Describe what the hazard is and what is wrong. Include the name of any chemicals or machinery involved.]

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Risk Assessment

Could this hazard cause serious injury or death right now?

[ ] YES (Stop work and notify supervisor immediately) [ ] NO

What could happen if this is not fixed?

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[List potential injuries or consequences, e.g., worker could fall and break leg, fire could start.]

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Suggested Action

What do you think should be done to fix this?

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[Suggest immediate controls, e.g., Clean up spill, Turn off power, Put up warning sign.]

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Management Response

To be completed by Supervisor or Manager

Action Taken / Recommended:

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Priority Level: [ ] Immediate (Stop work) [ ] High (Fix within 24 hours) [ ] Medium (Fix within 1 week) [ ] Low (Schedule for next maintenance)

Actioned By: [Name of Supervisor] Date: [DD/MM/YYYY] Signature: _____________________