Appendix E: Environmental Hazard Notification Form

Environmental Hazard Notification Form

Acumen Hotels
Organisation:

13 03 2022 06 57 Victoria
Date: / _/ _ Time: : PM/AM Region: Reported by:
Heshan
Who is at risk?: Client / ✔ Worker
**If only Client–Report on Client Support Concern Report

HAZARDIDENTIFIED:

A worker has tripped and fallen off stairs.

Worker to Complete

Nature of Risk: Slips, Trips, Falls/Noise/Cut/ Fire/ Workplace Environment/Electrical

Plant & Equipment/ Extreme Temperatures/ Ergonomics/Manual Handling/Other:

Trips and Falls

Name of witness(es) (If applicable)

Safety Officer 13 03 2022

Reported to: Date: / /

Corrective Action to be taken:

The individual to be given immediate first aid and to be taken to the hospital,

Hazard Control: Eliminated/Substituted/ Isolated/Engineering Controls/ Administrative/ Personal

Protective Equipment Used

Hazard and Corrective Action Recorded in Client Communication Book (If Applicable):
 YES  NO

Signed: _ _Date: /_____/ Telephone:

OFFICEUSE: Human Resources: Date Person Reporting Contacted: / /

Notes:

Responsible Person: Date: _______/_______/_______

 Feedback provided to person reporting Date: / /

 Feedback to Team Date: / /