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Safety Form

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Steps

1. Basic Hazard Information(current) This section is complete This section is incomplete
2. Risk Assessment This section is complete This section is incomplete
3. Recommendations This section is complete This section is incomplete
4. Contact Information This section is complete This section is incomplete

Basic Hazard Information

Date:*
Department:*
Description of safety concern or hazard:
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Risk Assessment

In your opinion, how likely is it that this hazard will lead to an event?
Probability (P) of an event happening:
1. Improbable (1)
2. Remote (2)
3. Occasional (3)
4. Probable (4)
5. Frequent (5)
What would be the outcome?
Severity (S) if an event happened:
1. NIL (1)
2. Negligible (2)
3. Marginal (3)
4. Critical (4)
5. Catastrophic (5)
Risk Rating
Multiply Probability by Severity (P x S = RR)
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Recommendations

Recommended preventative actions (if any):
Recommended contingency actions (if any):
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Contact Information

Contact Information Optional
Your name will not be seen by anyone other then the Safety Manager.
Name:
Position:
Phone:
Email:
Do you want feedback?
1. Yes
2. No

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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