Hazard report form*

NOTE: This form is for reporting hazards and is not a statutory (improvement or prohibition) notice under the
Workplace Health and Safety Act 1995.

Reference no.

Part A: Complete items 1-5 and give form to the employer, principal contractor, or WHSO
(1) Brief description of hazard/health and safety issue

The main drinking refrigerator is leaking water onto the floor

(2) Location of hazard in the workplace

It is located at the back of the convenience store, next to the ATM machine.

(3) Time/Date hazard identified

Time:

10

am

pm

Date:

01

/ /
08

2016

(4) Recommended remedial action to ensure workplace health and safety

Make sure that there are 'Wet Floor' signs next to the refrigerator and let all the customers
aware about the floor's condition.
01 08
Recommended completion date: / /

2016

(5) Please note: This report does not imply that all other conditions and work practices are acceptable
Reported by:

Name:

Received by: Jonathan Hawk

Employer
Principal contractor
Workplace Health and Safety Officer

Attendant

Larisse Gurgel Cirino Pinto

Name:

Signature:

Jonathan Hawk

Signature:

Contact number: ( )
+61
Date: / /
01
08

424649955

Contact number: ( )
+61

424659966

Date: / /
01
08

2016

2016
Part B: Description of remedial action taken to ensure workplace health and safety
A contractor was sent to repair the leaking at the same day. Leaking was successfully repaired.
Signs of 'Wet Floor' were all over the convenience store and no customers walked next to
the leaking
Reporting person:
Has the issue been satisfactorily addressed?

Yes

No

Completed on: / /
01
08
Reporting person signature: / /
James Bird
01
08

2016
2016

Part C: To be completed if the reporting person intends to notify an inspector

Contact details of employer/principal contractor
Name:
Address:

FORM 4

V 5.12.06
* Original to be retained by the reporting person.
* Copy to be given to the WHSO / employer / principal contractor as applicable.
* Copy to be forwarded to workplace health and safety inspector as applicable.

ABN 52 293 849 579

csq/06/2613

Contact number: ( )