Hazard Report Form
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
First/Last Name:
Center/Program :
Position:
Phone:
Supervisor/Manager:
! Employee
! Contractor /Volunteer ! Visitor
Student
2. Identify the hazard
Date hazard identified:
Time hazard identified:
Location of hazard if external give the nearest room: Campus:
Room:
Other:
Describe the Hazard:
Why/How is it a Hazard:
3. Assess the Risk
The risk rating of a hazard is based on the combination of likelihood, consequence and amount of exposure to a hazard.
Risk Assessment Matrix
How likely is it to be that serious?
Very likely
Likely
Unlikely
Very unlikely
1
1
2
3
1
2
3
4
2
3
4
5
3
4
5
6
Severityis 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.
Likelihoodis 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.
Consequences Table
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.
(Optional)
To be completed by Safet
y Department:
4. Corrective Action Plan How do you recommend the hazard is controlled?
Please use the Hierarchy of Controls to complete this corrective action plan, give priority to the hazard being eliminated.
1. Eliminate 2. Substitute 3. Engineering Control 4. Administrative Control 5. Personal Protective Equipment
Actions recommended to be taken
By Whom
By When
Consultation with work colleagues, management and other affected parties will assist in indentifying effective controls. Do not identify a person
to action an item unless you have spoken with them.
Manager/Supervisor to complete:
5. Have the control measures been implemented?
! YES
Date:
! NO
Provide comments on action taken to remedy the hazard; or proposed actions
Signature:
Email hazard report form to :
Date sent:
Campus Committee Comments
Provide comments on action taken to remedy the hazard or proposed actions
Health & Safety/Compliance Comments
Provide comments on action taken to remedy the hazard or proposed actions
Signature:
Is referral to senior management required?
! Yes
! No
Date Referred:
To whom:
Office Use only:
Follow Up:
Has the hazard been controlled effectively? What if any follow up action is required?
Is a follow up risk assessment required?
! Yes
! No
If Yes:
! 3
! 6
! 12
month(s)
Is entry onto the site Risk Register required?
! Yes
! No
Has the hazard been closed and or abated?:
Date:
Trevor.McMartin@mnwest.edu
To Submit Anonymously: Save this document to your desktop;
click button below; choose from computer; select document;
open; enter requested info; upload; You are done. Note: It will ask
for your name and email.This information will not be shown
Submit Via Email: Click the button below to
submit to Safety Manager. Your name will not
be given out; follow up will be made.
Submit to MN WEST Safety Drive
Email To Safety Manager
Mail to: Trevor McMartin
401 West St. Box 269
Jackson, MN 56143
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