Acorn SD HS SD7-C - Hazard Report Form V1.0 (ID 190932)

Hazard Report Form For reporting hazards or a hazardous situation. This form is for reporting hazards, complete this form if you notice a hazardous situation. Rectify the hazard immediately if you are able to do so and report what action you have taken. If unable to rectify the hazard, state what action you recommend. D ETAILS OF PERSON REPORTING THE HAZARD First name: _____________________________________________________________________________ Family name: ___________________________________________________________________________  Employee  Contractor/Volunteer  Visitor  Agency Casual Position:_______________________________________________________________________________ Department: ____________________________________________________________________________ Contact number: ________________________________________________________________________ I DENTIFY THE HAZARD Date hazard identified Time hazard identified Describe the hazard Location Why/how is it considered a hazard? Has the hazard already caused any harm/injury?  No  Yes – complete an incident report 891 D 9 A 0545 F 67 F 701935 FBB 715 A 693 C 6 CCC 08 B 11. DOCX © E RROR : R EFERENCE SOURCE NOT FOUND P AGE 1 ACORN COLLEGE HS HSD7 – HAZARD REPORT FORM V1.0 © 2021 E DUWORKS R ESOURCES

A SSESS THE RISK The risk rating of a hazard is based on the combination of likelihood, consequence and amount of exposure to a hazard.  Severity : is a measure of an injury, illness, incidents, or disease occurring. When assessing severity, the most severe category that would be most reasonably expected should be selected.  Likelihood : is defined as the potential that an accident will happen that may cause injury or harm to a person. When making assessment of likelihood, you must establish which of the categories most closely describes the probability of the hazardous incident occurring. C ONSEQUENCES TABLE  1 and 2 Extreme risk; consider elimination of the activity. Otherwise determine controls that are reasonably practicable to minimise the risk.  3 and 4 Moderate risk; determine controls that are reasonably practicable to minimise the risk.  5 and 6 Low risk; manage by routine procedures. R ISK ASSESSMENT MATRIX How SEVERE could the injury be? How LIKELY is it to be that serious? Very Likely Likely Unlikely Very unlikely Death or permanent disability Long term illness or serious injury Medical attention and several absentee days from school or work First aid needed C ORRECTIVE ACTION PLAN Please use the Hierarchy of Controls to complete the corrective action plan. Consultation with management and colleagues will assist in identifying effective controls. 1. Eliminate 2. Substitute 3. Engineering control 4. Administrative control 5. PPE 891 D 9 A 0545 F 67 F 701935 FBB 715 A 693 C 6 CCC 08 B 11. DOCX © E RROR : R EFERENCE SOURCE NOT FOUND P AGE 2 ACORN COLLEGE HS HSD7 – HAZARD REPORT FORM V1.0 © 2021 E DUWORKS R ESOURCES

F OLLOW UP (P RINCIPAL OR C HAIRMAN OF THE B OARD ONLY ) Has the hazard been controlled effectively? What if any follow up action is still required? Is a follow up risk assessment required?  No  Yes If Yes:  3 months  6 months  12 months Has the Risk Register been updated with this entry?  No  Yes Actioned by: Date: _____ / _____ / __________ 891 D 9 A 0545 F 67 F 701935 FBB 715 A 693 C 6 CCC 08 B 11. DOCX © E RROR : R EFERENCE SOURCE NOT FOUND P AGE 4 ACORN COLLEGE HS HSD7 – HAZARD REPORT FORM V1.0 © 2021 E DUWORKS R ESOURCES