HFORM02: Hazard Report Form¶
Form Reference: HFORM02 Version: 1.0 Classification: CRGI Information Form Owner: Sean Ashton, Operations Manager Purpose: Staff hazard reporting form for early identification of workplace hazards before they cause incident or injury per HPROC02. Enables staff to report unsafe conditions, practices or near misses.
Document Control¶
| Version | Date | Author | Change Summary |
|---|---|---|---|
| 1.0 | 10/03/2026 | Sean Ashton | Initial issue |
1. Reporter Details¶
| Field | Details |
|---|---|
| Reporter Name | _________________ |
| Role/Position | _________________ |
| Date of Report | _________________ |
| Contact Number | _________________ |
| _________________ |
2. Hazard Details¶
Location of Hazard¶
☐ Home Workstation
☐ Client Site
☐ Remote Location
☐ Travel (vehicle/commute)
☐ Other: _________________
Specific Location Details: _________________________________________________________________
Hazard Category (select one or more)¶
☐ Physical (slip, trip, fall, manual handling, machinery)
☐ Ergonomic (posture, workstation setup, repetitive strain)
☐ Environmental (temperature, humidity, lighting, noise)
☐ Chemical (cleaning products, solvents, exposure)
☐ Biological (contamination, infection risk)
☐ Psychosocial (stress, workload, harassment)
☐ Electrical (exposed wiring, overloads, damaged equipment)
☐ Fire (blocked exits, combustible materials, inadequate signage)
Hazard Description¶
What is the hazard? (Describe in detail)
Observations/Evidence:
Who Could Be Harmed?¶
☐ Reporter only
☐ Specific staff: _________________
☐ Multiple staff: _________________
☐ Visitors/contractors: _________________
☐ Public
Vulnerability factors (age, ability, experience, etc.): _____________________
How Could Harm Occur?¶
3. Risk Assessment¶
Initial Risk Rating (from reporter):
☐ Very Low (score 1–3)
☐ Low (score 4–6)
☐ Moderate (score 7–12)
☐ High (score 13–16)
☐ Very High (score 17–25)
Justification for risk rating:
Immediate danger? ☐ Yes ☐ No (If yes, area to be restricted immediately)
4. Immediate Actions Taken¶
What action did reporter take immediately (if any)?
Area secured/restricted? ☐ Yes ☐ No How? _________________________________________________________________
5. Recommended Further Actions¶
What does reporter recommend to address this hazard?
Estimated cost (if known): _________________
6. Management Response¶
To be completed by management within 5 working days
| Field | Details |
|---|---|
| Assessed by (name) | _________________ |
| Assessment date | _________________ |
| Revised risk rating | ☐ Very Low ☐ Low ☐ Moderate ☐ High ☐ Very High |
| Actions agreed | _________________ |
| Target completion date | _________________ |
| Responsible person | _________________ |
| HREG01 updated | ☐ Yes ☐ No |
| HREG03 updated | ☐ Yes ☐ No |
Management comments:
7. Sign-Off¶
| Role | Name | Signature | Date |
|---|---|---|---|
| Reporter | _________________ | _________________ | _________________ |
| Manager/Assessor | _________________ | _________________ | _________________ |
| Operations Manager (if High/Very High) | Sean Ashton | _________________ | _________________ |
Related Documents¶
- HPROC02: Hazard Identification & Control Procedure
- HREG03: Hazard Register
- HPOL04: Health & Safety Policy
- HFORM01: Risk Assessment Template
Document Footer¶
Retention: 3 years from report date Storage: CRGI Secure Document Management System Access: Reporter, Manager, Operations Manager, Health & Safety Representative Classification: CRGI Information — Internal Use Only
END OF FORM