Voluntary Safety Report The information supplied in this form will

Voluntary Safety Report
The information supplied in this form will only be used to enhance safety. You may
choose to not provide your name. If you do provide your name, upon receipt of this form
your name and position will be removed and discarded. Under no circumstances will
your identity be disclosed to any person in the airport or to any other organization,
agency or person without your express permission.
When you have completed your part of the form, it should be given to the Airport Safety
Officer or any member of the Airport Safety Committee.
Name: ______________________________________________
Organization Position: ___________________________________
[Name and position to be discarded by the Safety Officer]
PART A
TO BE COMPLETED BY THE PERSON IDENTIFYING THE HAZARD
Please fully describe the Hazard.
.
Date of occurrence: ___________________
Time: _________________
Location: _________________________
Description:____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________
In your opinion, what is the likelihood of a similar occurrence happening again?
Likely
1
2
3
4
Rare
5
What do you consider could be the worse possible consequence if this occurrence did
happen again?
Catastrophic
Minor damage
1
2
3
4
5
PART B
TO BE COMPLETED BY THE SAFETY OFFICER
The report has been de-identified and entered into the company database
Signature: ______________________ Date: ___________________
Name___________________________
Rate the likelihood of the hazard recurring
Very Likely
1
2
3
4
Rare
5
Rate the worst-case consequences
Catastrophic
1
2
4
Minor Damage
5
3
What action is required to ELIMINATE or CONTROL the hazard and PREVENT injury?
Resources Required:
______________________________________________________________________
Responsibility for action: __________________________________________________
______________________________________________________________________
Referred to ______________________ for further action.
Signature: ______________________________ Date: _________________
Forwarded to the Airport Safety Committee for review.
Signed: ________________________________ Date: _____________________
Appropriate Feedback given to staff.
Signed _______________________________ Date_________________