Hazard Form (Repair & Maintenance)

Fill out this form if you have seen a hazard that needs to be repaired or brought to the attention of WHS committee.

Hazard Form (Repair & Maintenance)

Name(Required)

First Last

Service(Required)

Date of identified hazard(Required)

Location of hazard(Required)

Brief description of hazard: (describe the task, equipment, tools and people involved. Include any action taken to ensure the safety of those who may be affected)(Required)

Select the consequence rating that applies to the hazard you are reporting(Required)

What is the timeframe to fix the hazard(Required)

Photo of hazard (if applicable)

Max. file size: 128 MB.

Signature(Required)