Online Form - 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 & Wellbeing Officer Lynsey Gannon on 08 9168 4100 or Lynsey.Gannon@swek.wa.gov.au

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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