EmailMe Form - LRPR Hazard Identification Form

Name *

First Last

Email

Phone

### - ### - ####

Date Time *

MM / DD / YYYY

Describe the Hazard: *

What are the risks associated with the hazard? *

Whom or what may be affected by the hazard? *

What has been done to control the hazard (if nothing has been done previously)? *

In your perception what is the current severity of Risk?

Risk Severity Categories

Minor
Minor injuries/first aid/Emergency Room/short-term discomfort possible; minor damage to equipment, structures, property possible - operational as is

Major
Major injuries/non-life threatening; temporary disability/short term hospitalization possible; major damage to equipment, structures, property possible - salvageable with repair

Severe
Severe Injuries to one/multiple persons; extensive hospitalization/permanent disability/disfigurement possible; severe damage/total loss of equipment, structures, property possible

Catastrophic
Multiple loss of life possible; Total destruction of equipment, structures, property possible *

Risk Severity

Please upload a photo of the Hazard