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Hazard Reporting Form
Hazard Reporting Form
This form is to be completed when a hazard has been identified or an WHS incident has occurred.
Name
Date of incident
Time of incident
Location
Reported to
Date reported
Description of hazard or incident
Employee to complete. Include details of task being performed, and a sequence of events
Select the appropriate category for the hazard or incident.
Slip, trip, fall
Equipment or machinery malfunction
Personal injury
Near miss (incident with potential for serious harm or injury)
Psychosocial hazard
Other
Please provide further information regarding the hazard or incident
Describe the nature and extent of the injuries if any.
Describe any treatments provided if any
Describe the immediate actions taken to address the incident and ensure safety.
Recommended measures to minimise chances of repeat occurrence or consequences
Please indicate which Psychosocial Hazard you are reporting.
Job demand
Job control
Support Systems
Role Clarity
Organisational Change
Job Demands
Identify tasks or responsibilities that may cause excessive stress or strain. Example high workload, tight deadlines, frequent overtime
Job control
Assess the level of control you have over your tasks and decisions. Example: Autonomy in decision-making, ability to influence
Support systems
Evaluate the availability of social and emotional support. Example: supervisor support, colleague interactions, employee assistance programs
Role clarity
Do you have clearly defined roles and responsibilities. Example: clear job descriptions, defined expectations
Organisational change
Consider the impact that organisation changes has on you. Example: Communication during change, employee involvement
Risk assessment
To be completed with manager
Exposure
Hazard - assess the duration, frequency and severity of exposure to each hazard. Use the scale (low, medium, high) to rate risks
Duration
Low
Medium
High
Frequency
Low
Medium
High
Severity
Low
Medium
High
Vulnerability
Identify vulnerable groups. Example: new employees, those with pre-existing mental health conditions
Combined Risks
Consider how multiple hazards interact and compound risks
Elimination
Can the hazard be eliminated?
Yes
No
How?
Minimisation
How can the risk be minimised?
Communication
Who
How
When
Add
Remove
Ensure clear communication about hazards and control measures
Monitor and review
When?
Who?
Outcome?
Add
Remove
Periodically review the effectiveness of control measures and adjust as needed
New Hazards
Have new hazards been identified?
Name
Employee
First
Last
Date
MM slash DD slash YYYY
Name
Manager
First
Last
Date
MM slash DD slash YYYY
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