Risk & Hazard Identification Form
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Hazard:
*
Description of Risk
*
Likelihood of Event
*
H
M
L
Potential Consequence
*
H
M
L
Likelihood Consequence
*
H
M
L
Suggested Controls for lowering Risk:
*
Submit
OFFICE USE ONLY
Name
First Name
Last Name
Discussed at H&S Committee Meeting:
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Feedback to Reporter:
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Added to Risk Register:
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Should be Empty: