Hazard Elimination Survey
Report and assess workplace hazards to help ensure a safer environment.
Your Name
*
First Name
Last Name
Department or Work Area
*
Date and Time of Observation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Hazard
*
Type of Hazard
*
Please Select
Physical
Chemical
Biological
Ergonomic
Psychosocial
Other
Describe the Hazard
*
How severe is the potential impact of this hazard?
*
Minor
1
2
3
4
Severe
5
1 is Minor, 5 is Severe
How likely is this hazard to cause harm?
*
Very Unlikely
Unlikely
Possible
Likely
Very Likely
Recommended Corrective Action
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of
Risk Assessment Matrix
Rows
Likelihood
Severity
Hazard Risk
Very Unlikely
Unlikely
Possible
Likely
Very Likely
Minor
Moderate
Major
Critical
Catastrophic
Has this hazard been eliminated?
*
Yes
No
In Progress
Additional Comments
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