Chemical Risk Assessment Form

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

Hazard Identification

• Add chemical in use

Chemical

• State/Figure

  Select Gas Vapor Mist Fume Dust Liquid Soild Other state/form

  • Gas
  • Vapor
  • Mist
  • Fume
  • Dust
  • Liquid
  • Soild
  • Other state/form

• What is this used for?

• Location of the process or work where the chemical is used

• People at Risk

  Select Employees Civilians Others

  • Employees
  • Civilians
  • Others

• other people at risk

• Hazard

  Select Acute Toxicity Very Toxic (fatal) Corrosive Harmful Explosive Serious eye irritation Respiratory Sensitiser Serious long term health hazard Oxidising Flammable Highly Flammable Extremely Flammable Dangerous to the environment Gasses under pressure

  • Acute Toxicity
  • Very Toxic (fatal)
  • Corrosive
  • Harmful
  • Explosive
  • Serious eye irritation
  • Respiratory Sensitiser
  • Serious long term health hazard
  • Oxidising
  • Flammable
  • Highly Flammable
  • Extremely Flammable
  • Dangerous to the environment
  • Gasses under pressure

• Indicate below which route(s) of exposure the substance takes

  Select Inhalation Skin Eyes Ingestion Other state

  • Inhalation
  • Skin
  • Eyes
  • Ingestion
  • Other state

• List the risks to health below from exposure to the substance

Containment and Disposal

• Containment measure and disposal method

Prevention of Hazards

• Prevention of Hazards

• Photos of identified hazards and annotations.

  Media

Risk Rating

• Is the exposure adequately controlled?

  Yes

  No

  N/A

• Risk rating after following control measures

  HIGH

  MEDIUM

  LOW

Recommendations

• Recommendations

Completion

• Full Name and Signature of the Inspector

  Sign