HAZARD REPORTING FORM

PERSON REPORTING :

DESCRIPTION OF HAZARD ( a hazard is an unsafe act or condition with the potential to cause harm) Location :

Details :

RISK POTENTIAL ( please detail any accident or near-miss experience )

ACTION TAKEN ( what have you already done to minimise the risk of any potential accident )

SIGNATURE :

DATE : NOW PASS TO LINE MANAGER / SAFETY OFFICER FOR FURTHER ACTION.

LINE MANAGER'S OBSERVATIONS AND COMMENTS :

ACTION TAKEN OR PROPOSED TO ELIMINATE HAZARD OR MINIMISE RISK :

SIGNATURE :

DATE : NOW PROVIDE FEEDBACK TO PERSON REPORTING THE HAZARD AND PROVIDE INFORMATION AND GUIDANCE TO ANYONE ELSE IT MAY AFFECT.

IF THE HAZARD IS CONSIDERED TO CONSTITUTE A SUBSTANTIAL RISK AND THE ACTIONS TAKEN HAVE NOT FULLY RESOLVED THE ISSUE THEN THIS FORM MUST BE PASSED TO THE MANAGING DIRECTOR FOR ATTENTION.
MANAGING DIRECTOR'S COMMENTS :

SIGNATURE : QCR 109

DATE: ISSUE 1

JUNE 2006