Hazard Report Form

For reporting hazards or a hazardous situation.

Complete this form if you notice a hazardous situation. Rectify the hazard immediately if you are able to do
so and report what action you have taken. If unable to rectify the hazard, state what action you recommend.

Details of Person Reporting the Hazard

First name: Harry

Family name: Jenkins

 Employee
 Client
 Contractor/Volunteer
 Visitor
 Agency Casual

Position: PCW

Department: Carer

Contact number: xx-xxx-xxx

Identify the Hazard

Date hazard identified 25 March 2024

Time hazard identified Around11:30 AM

Midway through Eldred’s occupational theraphy session.

Describe the hazard Eldred suddenly vomits during therapy session, indicating a potential health
issue, possibly gastroenteritis.

Location Banksia Care Facility

Why/how is it The vomit could contain infectious agent , posing a risk of spreading
considered a hazard? gastroenteritis to other in the facility. Immediate cleaning and disifection are
necessary to prevent further spread of infection.

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Has the hazard already  No
caused any harm/injury?
 Yes – complete an incident report

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Assess the Risk

The risk rating of a hazard is based on the combination of likelihood, consequence and amount of
exposure to a hazard.
 Severity: is a measure of an injury, illness, incidents, or disease occurring. When assessing severity,
the most severe category that would be most reasonably expected should be selected.
 Likelihood: is defined as the potential that an accident will happen that may cause injury or harm to a
person. When making assessment of likelihood, you must establish which of the categories most
closely describes the probability of the hazardous incident occurring.

Consequences Table

 1 and 2 Extreme risk; consider elimination of the activity. Otherwise determine controls that are
reasonably practicable to minimise the risk.
 3 and 4 Moderate risk; determine controls that are reasonably practicable to minimise the risk.
 5 and 6 Low risk; manage by routine procedures.

Risk Assessment Matrix

How severe could How likely is it to be that serious?

the injury be?
Very Likely Likely Unlikely Very unlikely

Death or permanent LOW

disability

Long term illness or LOW

serious injury

Medical attention and MEDIUM

several absentee days
from school or work

First aid needed HIGH

Corrective Action Plan

Please use the Hierarchy of Controls to complete the corrective action plan. Consultation with
management and colleagues will assist in identifying effective controls.
1. Eliminate
2. Substitute
3. Engineering control
4. Administrative control
5. PPE.

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Actions Recommended to be Taken By whom? By when?

Assure first aid providor to Eldred RN ASAP

Signs to prevent approaching vomited area Staff/support worker After proving first aid

Cleaning agent Staff/support worker ASAP

Use PPE Staff/support worker ASAP

Proper disposal of cleaning agent Staff/support worker ASAP

Have the Control Measures Been Implemented?

Residential Manager or Care Coordinator to complete.

 Yes
 No
Provide comments on action taken to remedy the hazard or proposed actions:
As soon as Eldred is given first aid assistance, the next step secure the area where the incident happen,
putting signage.
Vomit has been cleaned by support worker using infection protection and control policy and procedure
Use of PPE donning and doffing
Proper disposal of PPE use in designated bag/plastic

Name: Harry Jenkins

Signature:

Date: 25 Mar. 24

* Form is to be emailed to the management team

Date emailed: Supervisor

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Follow Up (Principal or Chairman of the Board Only)

Has the hazard been controlled effectively? What if any follow up action is still required?

Yes, hazard effectively controlled reported and documented.

Staff follow up annually for manual handling for update and upgrade.

Is a follow up risk assessment required?  No

 Yes
If Yes:
 3 months
 6 months
 12 months

Has the Risk Register been updated with this  No

entry?
 Yes

Actioned by: Harry Jenkins Date: 25 March 2024

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