Hazard report

Use this form in your workplace to report health and safety hazards and incidents. To notify SafeWork NSW of an incident, call 13 10 50.

Name of person completing this form:

First Name

Last Name

Email of person completing this form:

Hazard description:

Brief description of hazard/incident: (Describe the task, equipment, tools and people involved. Use sketches, if necessary. Include any action taken to ensure the safety of those who may be affected.)

Where is the hazard located in the workplace?

When was the hazard identified?

YYYY

What time was the hazard identified?

Hour

Minute

Second

Recommended action to fix hazard:

(List any suggestions you may have for reducing or eliminating the problem – for example re-design mechanical devices, update procedures, improve training, maintenance work)

incident/accident report

Hazard report

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