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    Hazard Report Form EDITADO

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    Anonymous SdrscPC4j
    This hazard report form documents a leaking refrigerator at a convenience store. It notes the location of the refrigerator next to the ATM, and recommends placing "Wet Floor" signs and notifying customers. The form was submitted by an attendant to the store manager, and details the repair of the leak by a contractor and use of warning signs to address the hazard. The reporting person confirms the issue was satisfactorily resolved.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Hazard Report Form EDITADO

    Uploaded by

    Anonymous SdrscPC4j
    197 views1 page
    This hazard report form documents a leaking refrigerator at a convenience store. It notes the location of the refrigerator next to the ATM, and recommends placing "Wet Floor" signs and notifying customers. The form was submitted by an attendant to the store manager, and details the repair of the leak by a contractor and use of warning signs to address the hazard. The reporting person confirms the issue was satisfactorily resolved.

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    Hazard Report

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    This hazard report form documents a leaking refrigerator at a convenience store. It notes the location of the refrigerator next to the ATM, and recommends placing "Wet Floor" signs and notifying customers. The form was submitted by an attendant to the store manager, and details the repair of the leak by a contractor and use of warning signs to address the hazard. The reporting person confirms the issue was satisfactorily resolved.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    197 views1 page

    Hazard Report Form EDITADO

    Uploaded by

    Anonymous SdrscPC4j
    This hazard report form documents a leaking refrigerator at a convenience store. It notes the location of the refrigerator next to the ATM, and recommends placing "Wet Floor" signs and notifying customers. The form was submitted by an attendant to the store manager, and details the repair of the leak by a contractor and use of warning signs to address the hazard. The reporting person confirms the issue was satisfactorily resolved.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    Hazard report form*

    NOTE: This form is for reporting hazards and is not a statutory (improvement or prohibition) notice under the
    Workplace Health and Safety Act 1995.

    Reference no.

    Part A: Complete items 1-5 and give form to the employer, principal contractor, or WHSO
    (1) Brief description of hazard/health and safety issue

    The main drinking refrigerator is leaking water onto the floor

    (2) Location of hazard in the workplace

    It is located at the back of the convenience store, next to the ATM machine.

    (3) Time/Date hazard identified


    Time:

    10

    am

    pm

    Date:

    01

    / /
    08

    2016

    (4) Recommended remedial action to ensure workplace health and safety

    Make sure that there are 'Wet Floor' signs next to the refrigerator and let all the customers
    aware about the floor's condition.
    01 08
    Recommended completion date: / /

    2016

    (5) Please note: This report does not imply that all other conditions and work practices are acceptable
    Reported by:

    Name:

    Received by: Jonathan Hawk


    Employer
    Principal contractor
    Workplace Health and Safety Officer

    Attendant

    Larisse Gurgel Cirino Pinto

    Name:

    Signature:

    Jonathan Hawk

    Signature:

    Contact number: ( )
    +61
    Date: / /
    01
    08

    424649955

    Contact number: ( )
    +61

    424659966

    Date: / /
    01
    08

    2016

    2016
    Part B: Description of remedial action taken to ensure workplace health and safety
    A contractor was sent to repair the leaking at the same day. Leaking was successfully repaired.
    Signs of 'Wet Floor' were all over the convenience store and no customers walked next to
    the leaking
    Reporting person:
    Has the issue been satisfactorily addressed?

    Yes

    No

    Completed on: / /
    01
    08
    Reporting person signature: / /
    James Bird
    01
    08

    2016
    2016

    Part C: To be completed if the reporting person intends to notify an inspector


    Contact details of employer/principal contractor
    Name:
    Address:

    FORM 4

    V 5.12.06
    * Original to be retained by the reporting person.
    * Copy to be given to the WHSO / employer / principal contractor as applicable.
    * Copy to be forwarded to workplace health and safety inspector as applicable.

    ABN 52 293 849 579

    csq/06/2613

    Contact number: ( )

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