HAZARD REPORT & INVESTIGATION

“Matching the right people to you”

IMPORTANT!

This document is for hazards only: Not incidents (damages) or accidents (injuries) All hazards with a Consequence 3 must be reported within 24 hours All hazards consequence 3 must be investigated within 5 working days

1	DETAILS OF PERSON COMPLETING THIS FORM

Surname:	First Name(s):
Contact Phone No:	Reporting Date:	20/03/2021 1:52:23 PM
Email:

2	DETAILS OF PREMISES WHERE HAZARD OCCURRED

Site:
Address:
State:	Site Manager Name
Phone:	Contact No.

3	HAZARD DETAILS

Date of hazard:	Click or tap to enter a date.

Time of hazard:	:	☐ AM ☐ PM

TYPE OF HAZARD?

☐ Near miss

☐ Workplace hazard

☐ Hazardous work practice

☐ Security

☐ Others (if others please describe)

DETAILS OF HAZARD:

WITNESSES: Were there any witnesses?	☐ Yes	☐ No
Name:	Contact:
Name:	Contact:

Who was the hazard reported to?	Position:

Are there any photographic images of the hazard?	☐ Yes	☐ No
Was the accident caught on CCTV?	☐ Yes	☐ No

Pic No. 1(Click on the centre icon to add pic ) Pic No.2 (Click on the centre icon to add pic )

When lodging this Report please ensure you include any and all videos and/or photos

4.CORRECTIVE/ PREVENTATIVE ACTION (Supervisor or site in charge to complete section 4.)

Was this hazard preventable?	☐ Yes	☐ No

If Yes, How?

If No, Why Not?

What countermeasures are we going to take to reduce the risk of this hazard occurring again?	Countermeasure	By When?	By Whom?

1
2
3

Refer to the 3 x 3 YL risk matrix and identify a risk rating. The hazard must be included on the hazard register.

Budget workforce WHS /OHS RISK MATRIX
Consequences of injury	Likelihood of incident Occurring
Likely (3) (high chance)	Possible (2) (medium chance)	Rare (1) (low Chance)
Major (Deaths) (3)	6	5	4
Moderate (Broken Bone) (2)	5	4	3
Minor (Cut/Bruise) (1)	4	3	2
Consequences +Likelihood=Rating E.g. consequences 3+likelihood2= Rating5 Rating numbers (5+6) which is an unacceptable level. These hazards/near misses must be communicated to the safety manger, Safety manager, safety advisor, regional manager & site manager. Work must stop until controls are implemented by and WHS /OHS committee to reduce the hazard rating to an acceptable rating 4 or below before work commences A risk rating will be established at the point of hazard being identified and again after control have been implemented. The risk rating should have reduced after controls put in place.

After controls have been implemented, conduct another risk assessment. The likelihood & rating should reduce

5.

Consequence:	Likelihood	Rating:

☐ By ticking this box ,I confirm that all the information I have provide is true and accurate to the best of my knowledge . I also acknowledged all budget workforce terms and conditions, privacy policies and local laws.

DATE:

Click or tap to enter a date.

Name of Person completing this report:	Name of Operational Owner