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Hazard Identification Form

Workplace hazard reporting and risk control record

Company logo

PAGE 1 OF 2

Workplace Details

Site / location

Department / area

Date

Reported by

Role / position

Hazard Register

Record each hazard identified. Rate risk as H = High, M = Medium, L = Low based on likelihood and consequence.

#	Hazard description	Location / area	Risk (H/M/L)	Existing controls	Recommended action	Responsible person	Due date
1
2
3
4
5
6

Hazard Identification Form - Page 2 of 2

Site

Date

Hazard Register (continued)

#	Hazard description	Location / area	Risk (H/M/L)	Existing controls	Recommended action	Responsible person	Due date
7
8
9
10

Additional Observations

Actions Summary

Action	Responsible	Due date	Completed

Declaration

I confirm that the hazards listed in this form have been identified through workplace observation and/or consultation with workers. The information recorded is accurate to the best of my knowledge. All identified hazards have been reported to the relevant supervisor or WHS officer for review and action.

Reported by

Name

Signature

Date

Reviewed by / WHS officer

Name

Signature

Date