Hazard Report Form - Section One

Please complete the form below. A copy will be sent to your email address to be forwarded to your direct supervisor for completion of Section Two. A copy of this report will also be emailed to safety@swek.wa.gov.au immediately after completion. If you have any questions, please contact safety@swek.wa.gov.au or call 08 9168 4100 and ask for Stephen or Ian.

Section one

This section is to be completed by person report the hazard

Employment type*

EmployeeContractorVisitorVolunteerOther

If other, please specify

Completed by (please enter your name)*

Employee email*

Supervisor Name*

Department*

Location of Potential Hazard*

Detail Description of Potential Hazard*

Potential hazard impact*

SafetyEnvironmentPropertyOther

If other, please specify

Potential Risks if Hazard not rectified*

Please type in your full name. By typing in your name, you are agreeing that the above information is correct.*

Date*

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