Hazard Identification Report Form

Reported by: *

Date *

Participant Name *

Location *

Description of Hazard/Risk: *

Risk rate: *

High Medium Low

Does any process/procedure exist for this hazard/risk/near miss? *

Yes No

Is the risk acceptable? *

Yes No

Is the existing process/procedure *

Effective Partially effective Ineffective?

Immediate actions and measures to be taken: *

CA Responsible Person

Position:

Phone:

CA Status:

Open More Action Required Closed effectively

CA Deadline Date

Description of actions:

Outcomes:

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

NDIS consultation required?

Yes No

If yes; has NDIS been contacted?

Yes No

If yes, date of NDIS consultation.

Report completed by:

Date / Time

Any comments

Signature

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