Hazard Report Form
This form is for reporting hazards, 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 and give
this report to.
1. Details of person reporting hazard
First Name: Family Name:
Centre/Program:
Position: Phone (w): Phone (h or m):
Supervisor/Manager:
Employee Contractor /Volunteer Visitor Agency Casual
2. Identify the hazard
Date hazard identified: Time hazard identified: am/pm
Location of hazard – if external give the
the nearest Room:
Level: Room: Playground:
Other:
Describe the Hazard:
Why/How is it a Hazard:
3. Assess the Risk
The risk rating of a hazard is based on the combination of likelihood, consequence and amount of exposure to a hazard.
Risk Assessment Matrix
How likely is it to be that serious?
How serious could the injury be?
Very likely Likely Unlikely Very unlikely
Death or permanent disability 1 1 2 3
Long term illness or serious injury 1 2 3 4
Medical attention and several days off 2 3 4 5
First aid needed 3 4 5 6
Severity – is a measure of an injury, illness, incidents, or Likelihood – is defined as the potential that an accident
disease occurring. When assessing severity, the most will happen that may cause injury or harm to a person.
severe category that would be most reasonably When making assessment of likelihood, you must
expected should be selected. establish which of the categories most closely describes
the probability of the hazardous incident occurring.
Consequences Table
Version: 003
Responsibility: Compliance Campus: All
Last reviewed: 02 February 2024 RTO No: 45365
Next review: 01 February 2025 CRICOS No: 03691K
Page 1 of 3
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.
4. Corrective Action Plan – How do you recommend the hazard is controlled?
Please use the Hierarchy of Controls to complete this corrective action plan, give priority to the hazard being eliminated.
1. Eliminate 2. Substitute 3. Engineering Control 4. Administrative Control 5. Personal Protective Equipment
Actions recommended to be taken By Whom By When
Consultation with work colleagues, management and other affected parties will assist in identifying effective controls. Do not
identify a person to action an item unless you have spoken with them.
Manager/Supervisor to complete:
5. Have the control measures been implemented?
YES Date: NO
Provide comments on action taken to remedy the hazard; or proposed actions
Signature:
Fax/email hazard report form 1. Compliance Manager Date sent:
to :
2. CEO (if applicable)
H&S Committee Comments
Provide comments on action taken to remedy the hazard or proposed
actions
<Compliance Manager> Comments
Provide comments on action taken to remedy the hazard or proposed
actions
Signature:
Is referral to senior management required? Yes No Date Referred: To whom:
Office Use only:
<CEO> Follow Up
Version: 003
Responsibility: Compliance Campus: All
Last reviewed: 02 February 2024 RTO No: 45365
Next review: 01 February 2025 CRICOS No: 03691K
Page 2 of 3
Has the hazard been controlled effectively? What if any follow up action is
required?
Is a follow up risk assessment required? Yes No If Yes: 3 6 12 months
Is entry onto the site Risk Register required? Yes No
Actioned by: Date:
Version: 003
Responsibility: Compliance Campus: All
Last reviewed: 02 February 2024 RTO No: 45365
Next review: 01 February 2025 CRICOS No: 03691K
Page 3 of 3
