Hazard Report Form: Workplace South Brisbane Institute

Workplace South Brisbane Institute
Hazard report form

This form is to be used in conjunction with Procedure No. 8852 – Workplace Health and Safety Risk Management
Processes. Forms must be forwarded to your manager and a copy of the completed form sent to your Workplace Health and
Safety Representative (WHSR).
Actions I can take!

Fix hazards straight away if you can.
Report all hazards using this form immediately,
even if you have fixed it.
“Make the Change” by starting at the top of the
control pyramid.
Complete this form and forward to your manager.
DON’T IGNORE IT … CHANGE IT
Consequence
Medical treatment
Near miss or no required for Extensive injuries Fatality, loss of
First aid / casualty
injury. injuries and lost time requiring limb. Major
treatment.
Low financial loss. recorded. No hospitalisation. Incident
hospitalisation.
Likelihood Insignificant Negligible Moderate Extensive Significant
Is expected to occur
in most
Almost 3 2 1 1 1
Certain (Medium Priority) (High Priority) (Urgent) (Urgent) (Urgent)
circumstances
Will probably occur
in most Likely 4 3 2 1 1
circumstances (Low Priority) (Medium Priority) (High Priority) (Urgent) (Urgent)
Might occur at some

Possible 4 4 3 2 1
time (Low Priority) (Low Priority) (Medium Priority) (High Priority) (Urgent)
Could occur at
Unlikely 5 5 4 3 2
some time (Monitor) (Monitor) (Low Priority) (Medium Priority) (High Priority)
May occur only in
exceptional Rare 5 5 5 4 3
circumstances (Monitor) (Monitor) (Monitor) (Low Priority) (Medium Priority)
Hazard Details:
1. Detailed description of hazard (include time, date, location and all relevant details):
In room 3022 at G Block at TAFE Brisbane South Bank campus, there is an area where there is a poor lighting, causing
headache to some students. This hazard has been detected the 12/04/2014 at 8:03pm. The area mentioned is in the top
right corner of the room once you enter to it and facing the window across.
2. Risk Score (justify Likelihood and Consequence):
This headache could occur at some time, really unlikely, causing insignificant consequences. Risk score 5.
3. Immediate actions taken by you:
I proceeded to check the lights in that area redistributed some workplaces and created a report QF058.
4. Further Recommendations for rectification:
I have noticed that there were some lights missing, which is the main problem, reinstalling all the lights missing may solve it.
QF058 Page 1 of 3
Human Resources RTO No. 0275 | CRICOS Provider No. 03020E
Version 2.0 - 22 May 2013
Template current as of 20/02/2013 – Version 3.1
Reported by: (must be completed)

Name: Marc Sole Ponte Department: Maintenance
Telephone: 0410203958 Signed: MSP Date: 12/04/2014

If risk score is rated as 1, 2 or 3, Manager must complete a Risk Assessment Form – QF059
Manager Comments/Action:
WHSO use only
Hazard ID:
Entered:
Signed:
Name:
Signed: Date:
QF058 Page 2 of 3
WHS risk score calculator

The level of risk is determined by both the likelihood and the severity of the consequences, and can be calculated using the
Risk Score Calculator (refer to pervious page).
1 URGENT – Immediate action required
2 HIGH PRIORITY – Action required ASAP
3 MEDIUM PRIORITY – Action required
4 LOW PRIORITY – If hazard increases in risk, take action
5 MONITOR RISK – Hazard may not need immediate attention
LIKELIHOOD
Almost Certain Likely Possible Unlikely Rare
Is expected to occur in Will probably occur in most Might occur at some May occur only in exceptional
Could occur at some time
most circumstances circumstances time circumstances
Has occurred in the last few Has never occurred in this

Has occurred on an Has occurred at least Is possible but has not
years in this Institute or has Institute but has occurred
annual basis in the once in the history of occurred to date in any similar
occurred recently in other infrequently in other similar
Institute in the past or this Institute or is organisation and is
similar organisations or organisations or is
circumstances are in considered to have a considered to have very much
circumstances have occurred considered to have a 1%
train that will cause it to 5% chance of occurring less than 1% chance of
that will cause it to happen in chance of occurring in the
happen in the next few years occurring in the short term
the next few years next few years
CONSEQUENCE
Significant Extensive Moderate Negligible Insignificant
Medical treatment required for

Fatality, loss of limb. Extensive injuries requiring First aid / casualty Near miss or no injury.
injuries and lost time
Major Incident hospitalisation. treatment.
recorded. No hospitalisation.
WHS hierarchy of control measures

HIERARCHY OF CONTROL MEASURES
Elimination Most Effective Option – Control the hazard at the source. This is the most effective control measure and
removes the risk by removing the hazard or changing the work processes.
Substitution Involves replacing the hazard with one that presents a lower risk.
Isolation Remove or separate people from the source of the hazard.
Engineering Involves structural change to the work environment or work process to place a barrier to, or interrupt a
transmission path between the worker and the hazard.
Administrative Reduces exposure to a hazard by adherence to procedures, instructions or training. Administrative controls
are dependent on human behaviour for success.
Personal Protective Provides a barrier between a person and the hazard. This is dependent on PPE being chosen correctly, as
Equipment well as fitted and worn at all times when required.
QF058 Page 3 of 3

Hazard Report Form: Workplace South Brisbane Institute

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Workplace South Brisbane Institute

Hazard report form

Actions I can take!

Might occur at some

2. Risk Score (justify Likelihood and Consequence):

3. Immediate actions taken by you:

4. Further Recommendations for rectification:

Reported by: (must be completed)

Telephone: 0410203958 Signed: MSP Date: 12/04/2014

WHSO use only

WHS risk score calculator

1 URGENT – Immediate action required

2 HIGH PRIORITY – Action required ASAP

3 MEDIUM PRIORITY – Action required

4 LOW PRIORITY – If hazard increases in risk, take action

5 MONITOR RISK – Hazard may not need immediate attention

Almost Certain Likely Possible Unlikely Rare

Has occurred in the last few Has never occurred in this

Significant Extensive Moderate Negligible Insignificant

Medical treatment required for

WHS hierarchy of control measures

Isolation Remove or separate people from the source of the hazard.

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