Hazard Identification Report

Hazard, Risk or Near Miss Report Form

Reporting Details, Hazard Classification, Risk Assessment, and Corrective Actions.

Reporting Details

Reported by (Worker):
Location: (Where the hazard/risk has been identified or near missed has happened)
Date:

Type of Hazard

Tick the appropriate box

Category	Specific Hazards / Sub-categories
Manual Handling	☐ Postures & Positions ☐ Lifting, pulling, pushing loads ☐ Carrying or holding ☐ Repetitive work ☐ Awkward working postures ☐ Application of force ☐ Static postures ☐ Use of force ☐ Inadequate activity variation
Physical	☐ Contagious disease/Viral/Bacterial ☐ Handling needles, syringes and other sharps
Hazardous substances	☐ Floor strippers ☐ Carpet cleaners and spotters ☐ Oven cleaners ☐ Strong bleaches
Mechanical/Electrical	☐ Overloaded power boards ☐ Frayed or broken electrical cords and damaged plugs ☐ Long or multiple extension leads ☐ Water around plugs, leads and equipment ☐ Overheated machine ☐ Lack of maintenance ☐ Broken machines ☐ Restricted access to power points
Environment	☐ Floor surface and condition ☐ Floor contamination ☐ Unexpected objects on the floor ☐ Clutter/space and design ☐ Stairs and stepladders ☐ Unsuitable work height ☐ Poor ventilation ☐ Poor lighting ☐ Pets/vermin ☐ Slippery/uneven surfaces
Psychological	☐ Client/Participant behaviour ☐ Sexual harassment ☐ Work pressure ☐ Bullying

Hazard/Risk or Near Miss Details

Description of Hazard (Include area and task involved, and any equipment, tools, people involved)
Required immediate action required? (Y/N)
If “Yes”, please specify

Risk Assessment

Risk rate:	☐ High ☐ Medium ☐ Low
Does any process/procedure exist for this hazard/risk/near miss?	☐ Yes ☐ No
Is the existing process/procedure	☐ Effective ☐ Partially effective ☐ Ineffective?
Is the risk acceptable?	☐ Yes ☐ No

Corrective Actions & Outcomes

Corrective Actions (CA) (List any suggestions you have for reducing or eliminating the hazards)
CA Responsible:
Position:
CA Deadline:
CA Status:	☐ Open ☐ More action required ☐ Closed effectively
Comments:

Outcomes:

☐ Run training/induction session
☐ Review/amend relevant process/documents
☐ Review/update risk register
☐ Create a new procedure
☐ Others:

Notification

NDIS consultation required?	☐ Yes ☐ No
If yes; date of consultation:	DD / MM / YYYY

Sign off

Risk assessment conducted by:
Date:
Signature: