subject_line
Hazard Report Form
please complete when identifying actual or potential hazards. Staff are reminded that they have a personal responsibility and duty of care to take immediate action to control any hazards identified.
Staff to Complete
Date Logged
*
+
Time Logged
*
Logged By
*
Involved Persons
Describe the Hazard
*
Immediate Action Taken or Suggested Action if any
*
Name
*
Date
*
+
Signature
*
clear
Coordinator/Case Manager/HR to Complete
Date Received
+
What priority should the hazard be given?
Extreme
High
Medium
Low
Other
Other
Hazard Logged on Database
Please see link below
Yes
No
Closure
Evaluation
(If Appropriate, describe how action/improvements were evaluated and the result)
Outcome or End Result
(Tick Applicable Box)
Issue Resolved - no Improvements Implemented
Improvements Implemented
Other - please specify below:
Other - please specify below:
Closed out/Complete?
Yes
No
Date
+
Case Manager/HR Manager Signature
clear
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