Safety Hazard
Notification and
Control Report
Part 1
Area of Work/Study
(Faculty/School)
(Division/Section)
Date
Reported by
(contact phone no.)
Specific hazard location
Hazard Report No:
(WHS Unit use
only)
Hazard Description:
Risk Assessment: (circle your estimate of the likelihood of this hazard resulting in an incident and the probable
consequences should such an event occur and using the matrix the overall risk rating ie Extreme (E) High(H),
Significant(S), Moderate(M) and Low(L))
RISK CALCULATOR (Risk Rating = Consequences x Likelihood)
CONSEQUENCE
LIKELIHOOD
Insignificant (1)
Minor (2)
Moderate (3)
Almost Certain
M (11)
H (13)
E (20)
(5)
Likely (4)
M (7)
H (12)
H (17)
Possible (3)
L (4)
M (8)
H 16)
Unlikely (2)
L (2)
L (5)
M (9)
Rare (1)
L (1)
L (3)
M (6)
Major (4)
E (23)
Catastrophic (5)
E (25)
E (21)
E (18)
H (15)
M (10)
E (24)
E (22)
E (19)
H (14)
Suggested Controls: (apply the hierarchy of control ie. elimination, substitution, isolation, engineering,
administration, personal protection)
Immediate Actions Taken
Having completed Part 1 forward the original to the Health Safety Representative (HSR) for the area
who will forward on to the area Organisational Unit head or Officer
Original report to be forwarded to the WHS Unit, Private Bag 46 Hobart 7001 Copy to file
Safety Hazard
Notification and
Control Report
Part 2
ACTION REQUIRED: (remember to apply the hierarchy of control)
Recommended Control(s):
Job Request Raised
yes
no
Job No(insert as appropriate)
Person Responsible
Controls to be completed by:
(date)
Approved by Organisational Unit
head/Officer
(name)
(signature)
Completion verified by Health
Safety Representative
(date)
(name)
(signature)
Original report to be forwarded to the WHS Unit, Private Bag 46 Hobart 7001 Copy to file