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