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Incident / Hazard Report Form: 1. Person Involved Details - Forward To Your Team Leader / Manager Within 24 Hours

An incident/hazard report form documents an event involving a person at a workplace. It collects details of the individual involved, date and time of occurrence, location, activity undertaken, description of the unexpected event, immediate response, perceived causes, and any witnesses. The person making the report signs and dates the form, which is then forwarded to a manager within 24 hours for evaluation of risk rating based on likelihood, consequence, and exposure to the hazard.

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146 views

Incident / Hazard Report Form: 1. Person Involved Details - Forward To Your Team Leader / Manager Within 24 Hours

An incident/hazard report form documents an event involving a person at a workplace. It collects details of the individual involved, date and time of occurrence, location, activity undertaken, description of the unexpected event, immediate response, perceived causes, and any witnesses. The person making the report signs and dates the form, which is then forwarded to a manager within 24 hours for evaluation of risk rating based on likelihood, consequence, and exposure to the hazard.

Uploaded by

titaandienti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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INCIDENT / HAZARD REPORT FORM

1. PERSON INVOLVED DETAILS - FORWARD TO YOUR TEAM LEADER / MANAGER WITHIN 24 HOURS
Position Title:
Name: Employee □ Visitor □
Address:
□ Contractor □ Visiting Student
□ Agency Personel
Phone:
e-mail: Employee Number / Student ID:

2. DETAILS OF INCIDENT / HAZARD


Date: Time: am/pm Location:

Where is the hazard located in the worksplace?

Act of Violence □ Injury / Illness □ Incident / Near Miss □


Hazard □ Property Damage □
What were you doing?
Describe the activity
undertaken at the time

What happened
unexpectedly? Describe
the incident / hazard as
it occurred

What did you do?


Describe what
happened next

What factors do you


feel caused this incident
/ hazard?

3. WERE THERE ANY WITNESSES? YES □ NO □


Name: Contact Phone Number:
Name: Contact Phone Number:

4. ASSESS THE RISK


The risk rating of a incident / hazard is based on the combination of likelihood, consequence, and amount
of exposure to a hazard
Print name of person making report Name :

Signature:

Date :

HAZARD RESPONSE & EVALUATION FORM

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