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Hazard identification and risk notification form
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Hazard Assessment
Complete each section. Use Notes column for additional detail.
| # | Item | Y | N | N/A | Notes / Detail |
|---|---|---|---|---|---|
| Hazard Identification | |||||
| 1 | Hazard type clearly described (physical, chemical, biological, ergonomic) | ||||
| 2 | Exact location of hazard identified and marked | ||||
| 3 | How hazard was discovered documented | ||||
| 4 | Potential harm or injury identified | ||||
| 5 | Number of workers potentially exposed assessed | ||||
| 6 | Photos or evidence of hazard captured | ||||
| Risk Assessment | |||||
| 7 | Likelihood of harm occurring rated (rare to almost certain) | ||||
| 8 | Consequence severity rated (insignificant to catastrophic) | ||||
| 9 | Overall risk rating calculated (low, medium, high, extreme) | ||||
| 10 | Existing controls in place identified | ||||
| 11 | Existing controls assessed for adequacy | ||||
| Immediate Actions | |||||
| 12 | Area made safe or isolated to prevent exposure | ||||
| 13 | Warning signs or barriers put in place | ||||
| 14 | Affected workers notified of hazard | ||||
| 15 | Supervisor or safety officer contacted | ||||
| 16 | Temporary controls implemented where practical | ||||
| Corrective Actions | |||||
| 17 | Hierarchy of controls applied (eliminate, substitute, isolate, engineer, admin, PPE) | ||||
| 18 | Responsible person assigned for corrective action | ||||
| 19 | Target completion date set for corrective action | ||||
| 20 | Budget or resources required identified | ||||
| 21 | Similar hazards in other areas checked | ||||
| Review & Close-out | |||||
| 22 | Corrective actions verified as effective | ||||
| 23 | Residual risk assessed after controls implemented | ||||
| 24 | Hazard register updated with findings | ||||
| 25 | Report closed out and signed off by safety officer | ||||
Declaration
I have reported this workplace hazard in good faith and to the best of my knowledge. I understand that all workers have a duty to report hazards and that no adverse action will be taken against anyone for making a hazard report.