OHS Hazard Report Form

Date:
Reported By:
Name:

Position:

Reported To:
Name:

Principal and OHS Rep

Position:

Principal and OHS Rep

Site location:
Subject:
Incident

Near Miss

Workplace Hazard

Description of Hazard:

Risk Assessment Levels

-How likely is the hazard to hurt me or someone else?

Not likely
Some likelihood
Quite likely
Extremely likely
-How badly could people be hurt?
Not badly
Somewhat badly
Quite badly
Extremely badly
Explain your answer here.

Hazardous Work Practice

What needs to be done?

Elimination
Substitution
Isolation
Safeguards
Instructing workers in the safest way to do something
Using personal protective equipment and clothing (PPE)
Other
Provide details below.

Signature:

Date:

Copy given to:

Manager:

(Signature)

Communication Meeting:

(Signature)