Form
Form - Hazard Report
Document FSSMS-FRM-34Stage 1Revision 3Version 0.3.3
Topic pages open on your jurisdiction, and requirements tables show its line. You can change this on any page.
The one-minute report of a hazardous condition: anything in a station, shop, training ground, vehicle or piece of equipment that could hurt someone. Any member may use it at any time, by any route: the paper copy at every station, the QR code or app where the department has one, a phone call, or a word to the officer, who then fills it in. Use Form - Near-Miss and Good-Catch Report for something that nearly happened; use this form for a condition. If unsure, use either; the health and safety officer sorts it. The officer applies an interim control the same shift for anything rated P1 (Imminent), the item enters the Corrective Action Register with its priority, and the reporter hears back within five working days (Workplace Inspections Program section 5.4). A documented route for reporting, evaluating and addressing hazards is an accreditation expectation (CPSE, 2019, criterion 11A.2), and rating follows the hazard identification method (CSA Z1002:12).
This report is about a condition, not a person. Reports made in good faith are protected: no reprisal, and a report is never used for discipline. You may leave your name off; then the answer is posted on the station safety board instead of sent to you.
| # | Question | Answer |
|---|---|---|
| 1 | What is the hazard? (plain words) | |
| 2 | Where exactly? (station; room or area; unit or equipment number) | |
| 3 | What could happen if nobody fixes it? | |
| 4 | What did you do about it, if anything? (told someone, tagged it, moved it, nothing yet) | |
| 5 | What would fix it? | |
| 6 | Date and time you noticed it; photograph attached (yes / no) | |
| 7 | How can we reach you to tell you what happened? (optional) |
| Field | Entry |
|---|---|
| Interim control and time: none needed / tagged out / barricaded / use stopped / isolated / other | |
| Priority on the department’s one scale: P1 (Imminent) / P2 (Serious) / P3 (Moderate) / P4 (Improvement) (table below); the same priority is recorded in the Corrective Action Register | |
| P1 items: district chief and health and safety officer told (time); fire chief and JOHSC co-chairs told within 24 hours (time) | |
| Work order number (facilities or fleet) | |
| Officer (role) and date |
Priority scale. The priority sets the interim control and the due dates, whatever the source of the finding:
| Priority | Meaning | Interim control | Plan due | Closure due | Extension and escalation |
|---|---|---|---|---|---|
| P1 (Imminent) | Could kill or seriously injure someone before the next shift or training night; a critical control absent or failed; a regulator stop-work order | Immediately, the same shift: stop the activity, isolate, tag out or remove from service; fire chief and JOHSC co-chairs told within 24 hours | 2 working days | 7 days | Fire chief may extend once, to 30 days, only with the interim control kept in place; fire chief informed at once if overdue |
| P2 (Serious) | A legal duty not met; a critical control weakened but not absent; injury likely within the month | Within 24 hours where practicable | 7 days | 30 days | Deputy chief may extend once, to 90 days; deputy chief at the due date, fire chief at 30 days overdue |
| P3 (Moderate) | An isolated lapse; injury potential that is not imminent | None beyond logging | 30 days | 90 days | Deputy chief may extend once, to 180 days; deputy chief at 30 days overdue, fire chief at 60 days |
| P4 (Improvement) | Housekeeping, comfort, an opportunity to be more effective | None | Next quarterly program update | 365 days or the next budget cycle, dated | Cancelled only with a written reason |
| Field | Entry |
|---|---|
| Report reference; date received; route (paper, QR or app, phone, verbal to officer) | |
| Register ID; owner (role); plan due and closure due (from the priority) | |
| Program it belongs to (facilities, apparatus, training, PPE, other) | |
| Also an event that nearly caused harm? Sent to triage on Form - Event Triage Record (yes / no) | |
| Reply to the reporter within five working days: date and summary (or posted on the safety board if anonymous) | |
| Closure verified by someone other than the person who fixed it (role, date, evidence) | |
| Reporter told the final outcome (date; or posted on the safety board if anonymous) | |
| Included in the JOHSC monthly summary (month) |
| Field | Type | Required | Who completes |
|---|---|---|---|
| Questions 1 to 5 | Free text | Questions 1 and 2 required; 3 to 5 optional | Reporter, or the officer on the reporter’s behalf |
| Date and time noticed; photograph | Date-time; file | Date required; photo optional | Reporter |
| Contact | Text | Optional | Reporter |
| Interim control and time | Pick list; time | Yes | Officer |
| Priority (P1 to P4) | Pick list | Yes | Officer; health and safety officer confirms |
| P1 notification times | Times | Yes for P1 items | Officer |
| Work order number | Text | Where one is raised | Officer |
| Report reference, date, route | Text; date; pick list | Yes | Health and safety officer |
| Register ID, owner, plan and closure due dates | Text; role; dates | Yes | Health and safety officer |
| Triage flag | Yes / no | Yes | Health and safety officer |
| Reply date and summary | Date; text | Yes | Health and safety officer or program manager |
| Closure verification | Role; date; evidence | Yes at closure | Verifier |
| Reporter told the final outcome | Date | Yes at closure | Health and safety officer or program manager |
| JOHSC summary month | Month | Yes | Health and safety officer |
Retention. Five years (05 Document Control and Records). Privacy. Reports name the condition, not a person; the monthly summary to the JOHSC is de-identified.
This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.
| Topic | What to check in your jurisdiction | Page |
|---|---|---|
| Hazard Assessment and Workplace Inspections | Whether the OHS program must include a system for reporting and controlling hazards (this form is that route), and any duty to assess hazards in writing | J04 Hazard Assessment and Workplace Inspections |
| Joint Committee and Health and Safety Representative | The committee’s statutory functions in receiving and helping resolve concerns and complaints (Part C’s monthly summary) | J05 Joint Committee and Health and Safety Representative |
| Right to Refuse and Reprisal Protection | Protection from reprisal for reporting a hazard or exercising a right under the OHS statute, the complaint route, and who bears the burden of proof | J07 Right to Refuse and Reprisal Protection |
| Records Retention | The default retention period for records the OHS law requires (this form is kept five years) | J09 Records Retention |
Center for Public Safety Excellence [CPSE]. (2019). Fire and emergency service self-assessment manual (10th ed.). Commission on Fire Accreditation International. https://cpse.org/wp-content/uploads/2019/08/10th-Edition-FESSAM-Strikethrough-Underline-v.4.pdf
CSA Group. (2012). CSA Z1002:12 (R2022), Occupational health and safety: Hazard identification and elimination and risk assessment and control. https://www.csagroup.org/store/product/CAN-CSA-Z1002-12/