Hazard Self Report

This is a tool to be used to report any hazards or near misses that you have witnessed while working for Workforce Express.

Hazards that have been reported will be followed up by Workforce Express with our client to maintain our duty of care and protect the health and safety of our candidates.

No names or identifying information are recorded to keep the process anonymous, however you are free to contact our office and/or the Workforce Express Safety Coordinator directly if you wish.

Type of Report*
- Hazard - Anything in the workplace that if left uncontrolled has the potential to cause harm to people.
- Near Hit - A situation or condition that has occurred that had the potential to cause injury or harm to people, but was narrowly avoided.
- Environmental - Conditions that have the potential to threaten the surrounding natural environment and adversely affect people's health.
Your Name (optional)
Site Where Event Occurred*
Specific Location on Site*
Event Time*

: HH

MM
Event Date*
Date Format: DD slash MM slash YYYY
Description of Event*
Describe the situation leading up to the event, the task being performed at the time, the event as it occurred, and anything that happened after the event.
Action Taken
Were there any immediate actions taken or controls put in place to eliminate or minimise further impact or occurrence?