Environmental Hazard Report Form
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1
2OFFICE USE:
REPORT NUMBER
_ _ - _ _ _ _
ENVIRONMENTAL HAZARD REPORT FORM
*Environmental Hazard Reports to be forwarded to: Manager, Human Resources, PO BOX 396, MARDEN, SA, 5070
PLEASE PRINT CLEARLY
Location Address: ____________________________________________________
Date:
_____/_____/_______
Time: _____:______PM/AM
Region: ____________________
Reported by: _____________________________ Who is at risk?:
Client
/
Worker
**If only Client – Report on Client Support Concern Report
HAZARD IDENTIFIED:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_____________________________________________
Nature of Risk: Slips, Trips, Falls / Noise / Cut / Fire / Workplace Environment / Electrical
Plant & Equipment / Extreme Temperatures / Ergonomics / Manual Handling / Other:
__________________________________________________________________________________
Name of witness(es) ________________________________________________ (If applicable)
R
eported to:_________________________________________
Date:
_____/_____/_______
Corrective Action to be taken:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Hazard Control: Eliminated / Substituted / Isolated / Engineering Controls / Administrative /
Personal Protective Equipment Used
__________________________________________________________________________________
Hazard and Corrective Action Recorded in Client Communication Book (If Applicable) :
/
YES
NO
Signed
Date:
Telephone:
: ______________________
____/____/____
_____________________
OFFICE USE:
Human Resources: Date Person Reporting Contacted: ____/____/_______
Notes:_____________________________________________________________________________________
Responsible Person: _________________________________________
Date:
____/____/_______
Feedback provided to person reporting
Date: ____/____/_______
Feedback to Team
Date: ____/____/_______
I:\PQA - Community\Forms and Letters\Work, Health and Safety v2 July 15
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