This form is for reporting hazards, complete this form if you notice a hazardous situation. Rectify the hazard immediately if you are able to do
so and report what action you have taken. If unable to rectify the hazard, state what action you recommend and submit this form to the
MN West Safety Department. See bottom of last page for ways to submit this form.
1. Details of person reporting hazard
! Contractor /Volunteer ! Visitor
Location of hazard – if external give the nearest room: Campus:
The risk rating of a hazard is based on the combination of likelihood, consequence and amount of exposure to a hazard.
How serious could the injury be?
How likely is it to be that serious?
Death or permanent disability
Long term illness or serious injury
Medical attention and several days off
Severity – is a measure of an injury, illness, incidents, or
disease occurring. When assessing severity, the most
severe category that would be most reasonably expected
should be selected.
Likelihood – is defined as the potential that an accident will
happen that may cause injury or harm to a person. When
making assessment of likelihood, you must establish which
of the categories most closely describes the probability of the
hazardous incident occurring.
1 and 2 Extreme risk; consider elimination of the activity. Otherwise determine controls that are reasonably
practicable to minimise the risk.
3 and 4 Moderate risk; determine controls that are reasonably practicable to minimise the risk.
5 and 6 Low risk; manage by routine procedures.
To be completed by Safet