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Hazard or maintenance report – blank worksheet

Download this guide as a PDF (English). In the Orchard Tech app, use Save on the document card to keep a copy for offline reading.

For immediate danger, stop, move to safety and tell the supervisor. Call 000 when emergency help is needed. Do not wait to complete a worksheet.

Use these blank notes to explain a hazard or maintenance problem. Do not approach a hazard or take a photograph if doing so creates a risk.

Blank private worksheet

Date and time noticed: _________________________________

Where the problem is: __________________________________

What I noticed: ________________________________________

Why it may be unsafe or need attention: ___________________

Safe action already taken, if any: ________________________

Who I told, and when: __________________________________

Further help or follow-up requested: ______________________

Tell your supervisor or Orchard Tech promptly using the workplace reporting arrangements. A written note does not show that the problem was received, fixed or resolved. Keep a completed worksheet private and ask how it should be returned. Do not use the app Contact feature to attach this sheet or send private incident or medical information.