Incident Hazard Report Form

Section 1: Reported By
Section 2: Hazard Details
(Complete This Section Only If No Injury Or Property Damage Has Occurred
Section 3: Hazard Details
(Complete This Section Only If No Injury Or Property Damage Has Occurred
Date & Time of Incident
MM slash DD slash YYYY
Time
:
Section 4: Declaration
I Hereby Declare The Information Provided Above Is True And Correct.
Signed On Behalf Of The Church
MM slash DD slash YYYY
Section 5: Investigation
(Completed Under The Direction Of The Responsible Officer Or WHS Co‐Ordinator)
Signed Responsible Officer
MM slash DD slash YYYY
Signed WHS Co‐Ordinator
 

Incident: Any event that gives rise to personal injury or damage to property, or has the potential to cause personal injury or property damage.

Hazard: Any physical condition that exists on the property that has the potential, if left unchanged, to cause personal injury or damage to property.