Sample Safety Manager Hazard Report

Below is a 9-point “Safety Manger Hazard Report” that can be used on the managerial side of the organization. Once hazard reports come into the appropriate department or the risk manager’s office, the appropriate response must be made to the person or persons reporting the potential hazard.

1. Hazard:

2. Reported By:

3. Date:

4. Circumstances:

5. Supplemental Data:

6. Safety Manager Analysis:

a. Confirmation:
b. Risk Analysis:
(1) Mishap Severity (L) ::::
(2) Mishap Probability (F) ::::
(3) Mishap Exposure (E) ::::

Risk ::: L x F x E ::::
Values Risk Level Action
80-100 Very High Discontinue, Stop
60-75 High immediate Correction
40-50 Substantial Correction Required
18-36 Possible Attention Needed
1-16 Slight Possibly Acceptable
0 None
C. Immediate Causes:
d. Basic Causes:
e. Lack of Control:

7. Corrective Actions Taken:

A. Immediate Cause Recommendations.
B. Basic Cause Recommendations.
C. Lack Of Control Recommendations.

8. Point Of Contact:

9. President/Ceo/General Manager’s Comments:

Working thru the form is more than just recording keeping. It has more to do with fulfilling the promises that were made to make and keep the organizations people and property safe from accidents and losses.

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