Basic Risk Assessment Template (HIRA)

• Prepared by

• Location
  Address

• Description of Activity

Safety team

• Margaret Breytenbach

  Sign

• Site Safety Officer

• Signature

  Sign

General

• Identify the task

Hazard, Risk, control

Hazard

• Hazard Identification

• Risk Identification

Initial Risk Assessment

• Likelihood

  A

  B

  C

  D

  E

• Consequence

  1 Negligible

  2 Minor

  3 Moderate

  4 Major

  5 Catastrophic

• Risk Level

  High

  Medium

  Low

• Risk Value

• Control measures

  Select Elimination Substitution Engineering Controls Administrative Controls PPE Other

  • Elimination
  • Substitution
  • Engineering Controls
  • Administrative Controls
  • PPE
  • Other

• Description of control measures

Residual Risk

• Likelihood

  A

  B

  C

  D

  E

• Consequence

  1 Negligible

  2 Minor

  3 Moderate

  4 Major

  5 Catastrophic

• Risk Level

  High

  Medium

  Low

• Risk Value

Recommended Additional control measures

• Description

Completion

• Signature

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