Hazard Identification Report Form

Step 1 of 3

Participant Name*

Reported by:*

Phone

Location*

Date of Birth*

Date of Hazard Risk / Near Miss*

Description of Hazard Risk / Near Miss

Risk Level*

High Medium Low

Does any process, policy and procedure already exist for this kind hazard risk / near miss?*

Yes No

Is the risk acceptable?*

Yes No

The existing process, policy and procedure is*

Effective Partially effective Ineffective

Immediate actions and measures to be taken:*

Step 2 of 3

CA Responsible Person

CA Status:

Open More Action Required Closed effectively

Position:

Phone:

CA Deadline Date

Description of actions:

Step 3 of 3

NDIS consultation required?

Yes No

If yes; has NDIS been contacted?

Yes No

If yes, date of NDIS consultation.

Report completed by:

Date / Time

Any comments

Signature