Your Business Name)
Hazard report form
Please print clearly
Location: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date:
Name:
.............................................
Reported to:
....................................
DESCRIPTION OF HAZARD:

Required

Worker to complete
Corrective Action: Taken
ACTION TAKEN:
Discussed at staff meeting/WHS committee
PCBU to complete
Discussed at staff meeting/WHS committee


Date: ........................
Date: ........................
FURTHER ACTION REQUIRED:
PCBU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Worker
.................................................
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .