A1 Disability Support Care

Brisbane: 07 3473 1700
Melbourne: 03 9970 1700
info@a1disabilitysupportcare.com.au

Mon - Friday 9am -5pm

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Hazard Identification And Report

Client Reference

Name

Address

Date of Birth

M/F/O

This Report is about identifying health and safety hazards in the client’s home. This form is to be given to the Care Manager / Coordinator by the Care Worker as soon as a hazard has been identified.

Date

Location of Hazard

REPORTED BY

Name

Position

REPORTED TO

Name

Position

IncidentNear MissWorkplace HazardHazardous Work Practice

DESCRIPTION OF HAZARD

WHAT IS THE PROBABLE CONSEQUENCE OF THE HAZARD

Life ThreateningHighMediumLow

DetrimentalHighMediumLow

HarmfulHighMediumLow

NegligibleHighMediumLow

WHAT IS THE PROBABLE FREQUENCY OF EXPOSURE TO THE HAZARD

TIMEFRAME OF ANY ACTION TO BE TAKEN

WHAT NEEDS TO BE DONE?

Signature:

Date

COPY GIVEN TO

Manager Name:

Signature

COMMUNICATION MEETING

Date

Venue:

Present:

Signature:

Present:

Signature:

At A1 Disability Support Care we are dedicated to enhancing the lives of individuals with disabilities across Queensland.

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