Form Builder

Your browser does not appear to support JavaScript. You may want to try one of the following:

Turn on JavaScript in your browser if it supports it.
Use a browser that supports JavaScript.
Try a JavaScript-free version of this page, if made available by the application author.

Help

$xforms-template-label$$xforms-template-help$$xforms-template-hint$$xforms-template-label$$xforms-template-help$$xforms-template-hint$

Application NameJSA Form NameJSA_HAZARD Form TitleHazard Form Description

Form Structure

Text Controls

Typed Controls

Date and Time

Selection Controls

Attachments

Buttons

Advanced

It appears that you are using Internet Explorer or earlier. Form Builder is likely not working properly with this browser. We recommend you upgrade to Internet Explorer or newer, or use Google Chrome, Firefox, Safari, or Opera. If we made a mistake and you are not using Internet Explorer or earlier, please let us know.

Form Settings

Report

Before completing this report, please follow these steps:

Make the hazard as safe as possible within your control.
If the hazard remains a significant risk, inform those who may be affected and do not leave it unattended.
If immediate action is required, contact your line manager (or their line manager if your line manager is unavailable).

Number
OrganisationRehab ManagementAimBigLiveBigArriba Corporate	Date hazard identifiedMissing or incorrect value	Location Type	Hazard location (Be Specific)e.g., "Next to the sink in the kitchen"
		Site false100
		Provide Detail (Car registration, client’s address, etc.)

Hazard Type (Other)

Hazard DescriptionDescribe the hazard and why it could cause harm

console

Risk

Indicator

Score

	Dimension	Degree	Score	Guidance
	Dimension	Degree	Score	Guidance

Immediate Actions TakenDescribe any actions taken to reduce the risk of the hazard

Suggestions for Removing or Reducing the Hazard

Person Reporting

Manager's Name(s)

Evaluation

Potential Harm

Uncontrolled Risk

Score

Indicator

If the uncontrolled risk rating is 7 or higher the safety hazard is significant and permanent controls must be put in placeSignificant Safety Hazard?

	Dimension	Degree	Score	Guidance
	Dimension	Degree	Score	Guidance

Controls

Controlled Risk

Score

IndicatorThe controlled risk rating must be 6 or lower, if not then other controls must be put in place

	Dimension	Degree	Score	Guidance
	Dimension	Degree	Score	Guidance

Review

Steps to Complete This Review

Identify immediate and long-term actions to manage the hazard.
Document these actions within this form when assigned.
Manage the actions through to completion to ensure the hazard is resolved.
Provide feedback and updates to workers on the actions taken to manage the hazard.

Review Due Date

Additional Actions Taken to Reduce Risk


Are Additional Actions Required to Remove or Reduce the Hazard?YesNo	Action(s)	Closed Actions
		Can be closed

Hazard

Date	Site false100	State	Reported By false100
Employee Name false100	Reported ByEmployeeContractor
Contractor Name	Employer	Address	Contact Details

CategoryFirst choiceSecond choiceThird choice	Description
Photo	Other Attachment
Active?

RISK DIMENSION DATA

Insert Below

Dimension

Degree First choiceSecond choiceThird choice

Guidance

Mark this checkbox if you'd like to type HTML tags Click to enter a label Type your label here Click to add a hint Type your hint here Click to enter text Type your text here Remove File

true

Add Language