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HAZARD REPORT FORM
A hazard is a situation which represents the potential for an incident, accident or near miss.  DO NOT use this form to report a near miss, incident or injury.  There is a confidential incident report form for that purpose. 
To be completed by the person reporting the hazard to the workplace management
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Name
Position
Manager/supervisor's name
Address
Phone number
Email address
Date & time of hazard
MM
/
DD
/
YYYY
Time
:
Description of hazard
Location of hazard
Clear selection
Name any witnesses involve + phone number
What do you think can be done to resolve the problem?
Immediate action taken when hazard identified
Who resolved the issue?
Submit
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