Reported by
Name Reports can be anonymous. Leave blank if you prefer
Role and work area
Date and time noticed
Contact number or email Only so we can ask follow-up questions
What is the hazard
Exact location Building, floor, room, machine number or route
Describe the hazard What you saw, not what you think caused it
Who could be harmed and how Workers, contractors, visitors, the public
Has anyone been hurt already If yes, stop and complete an incident report as well
Hazard category
Tick everything that applies. This drives who the report gets routed to.
- Slip, trip or fall hazard
- Working at height or fall from height
- Plant, machinery or equipment fault
- Vehicle, mobile plant or traffic interaction
- Electrical fault or damaged equipment
- Hazardous chemical, spill or labelling problem
- Fire, ignition source or blocked egress
- Manual handling or ergonomics
- Work-related violence, aggression or threatening behaviour
- Lone or isolated work with no reliable way to call for help
- Psychosocial hazard (workload, fatigue, bullying, exposure to trauma)
- Security, access control or lighting
- Housekeeping, storage or waste
- Other
Immediate action taken
What was done on the spot, before anyone assessed it properly. Interim controls count and should be recorded.
Action taken at the time Area taped off, machine tagged out, spill contained, task stopped
Is the hazard still present Yes or no. If yes, what is stopping people being exposed right now
Reported verbally to Name and time
Supervisor assessment
Completed by the supervisor or health and safety manager who receives the report. Rate the risk as it stands now, with any interim controls already in place.
| Likelihood | Consequence | Risk rating | Target fix date | Assessed by |
|---|---|---|---|---|
Controls and close-out
| Control to be implemented | Hierarchy level | Owner | Due date | Date completed |
|---|---|---|---|---|
Feedback to the reporter
Reporter informed on (date)
How In person, email, team meeting
Added to the risk register Yes or no, and the register reference
Tell the person who reported it what happened. This is the single biggest driver of whether anyone reports the next one. Record the date you closed the loop and how.
If the hazard cannot be fixed, say so and explain what interim controls will stay in place. An honest no is better than silence.