Part A: Person reporting the hazard to complete	
Name of person reporting the hazard:		
Date reported:	Reported To:		

Type of Hazard:	Posture/Overuse Ergonomic
Hazardous Manual Task(s) Biological and Infection Plant and Equipment Mechanical
Hazardous Chemicals Electrical
Working at Heights Slip/trip/fall	Environmental Security
Emergencies & Fire Safety Extreme Temperatures Traffic/ Vehicle Movement Psychological
Animal
Lack of or deficient PPE
Other: under the influence of alcohol	

Details of Hazard:		
Location of hazard:		
Assessment of hazard/risk:

Refer to Risk Assessment Matrix	Refer to Risk Assessment matrix (Please tick
one)	High Risk	Research and planning at CEO level. Report to Compliance Committee and Board	
		Significant Risk	Senior management attention needed	
		Moderate Risk	Management responsibility must be specified	
		Low Risk	Manage by routine procedures	
Referred to for action:	No action required	Date:		
Part B: Manager/Supervisor to complete.	Manager/Supervisor Name:	
Type of Solution:	Eliminate Substitute Engineering
Housekeeping	Equipment Purchase Reorganise Work Area Training
Requires new procedure	External Organisation Audit
Other	
Action taken:		
		
		Date:		
What follow-up action is required:		

Follow up By: NA	
Corrective Action Complete:	
Complete Incomplete	If Incomplete when will corrective action be completed:	
			
Managers/Supervisor signature:		Date:	
Reviewed	Complete Incomplete	Any Further Actions Required	

Managers/Supervisor signature:		Date:	
Part C: WHS Personnel to complete	
Tabled at WHS Committee	Yes	No	 Date:	
Corrective Action Complete:	
Complete Incomplete	If Incomplete when will corrective action be completed:	

WHS Personnel signature:		Date:	
Reviewed	Complete Incomplete	Any Further Actions Required	
WHS Personnel signature:		Date:	

Risk Likelihood	Risk Severity	
	Catastrophic 5	Hazardous 4	Major 3	Minor 2	Negligible 1	
Frequent 5	Unacceptable	Unacceptable	Unacceptable	Tolerable	Tolerable	
Occasional 4	Unacceptable	Unacceptable	Tolerable	Tolerable	Tolerable	
Remote 3	Unacceptable	Tolerable	Tolerable	Tolerable	Acceptable	
Improbable 2	Tolerable	Tolerable	Tolerable	Acceptable	Acceptable	
Extremely Improbable 1	
Tolerable	
Acceptable	
Acceptable	
Acceptable	
Acceptable	

Establish the severity & Assign a Rating of 1 to 5	
Level	Severity	Injury/Illness	Property Damage or loss	Environmental Impact	

1	
Negligible	Minor injury, 1st aid injury or report only	Low financial loss (<$20,000)	Limited damage to minimal area of low significance.	

2	
Minor	Reversible disability. Short term lost time injuries.	Medium financial loss (<$20,000 - $200,000)	Minor effects on biological or physical
environment.	

3	
Major	Short-term disabling; Moderate irreversible disability or impairment	High financial loss ($200,000
- $2M)	Moderate short-term effects but not affecting eco-system	
4	Hazardous	Single fatality and/or server disability	Major financial loss (<$2M -
$20M)	Serious medium term environmental effects.	

5	
Catastrophic	Multiple fatality and/or significant irreversible disability	
High to Extreme (loss
>$20M)	Very serious long term environmental impairment of eco-
system.	
Establish the likelihood of the event & Assign a Rating of 1-5	
1	Extremely Improbable	could happen in extreme circumstances	Rare	
2	Improbable	Has not happened yet but could	1 per 10 - years	
3	Remote	Could happen; has occurred elsewhere	1 per 1 - 10 years	
4	Occasional	Could easily happen	More than 1 event per year	
5	Frequent	Happens often	More than 1 per month