Construction Risk Assessment Form

• Site

  Select

• Conducted on

  Date

• Prepared by

  Select

• Other Attendees

  Select
• Location
  Address

• Proposed work description

• Photo of proposed work area

  Media

• Instructions
  -------------------------
  1. Answer "Safe", "At Risk", "N/A" for each of the hazards below
  2. If "At Risk", follow the questions to identify the likelihood of occurrence, severity and risk rating
  3. Include any notes and photos by clicking on the paperclip icon and then "Add Image"
  4. Answer the relevant control questions
  5. Complete the form by providing the relevant signatures

Confined Space

• Confined Space

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Confined Space permit received

  Yes

  No

  N/A

• Enter description of risk & control measures

• Add Photos

  Media

Working at Height

• Working at Height

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Working at height permit required

  Yes

  No

  N/A

• EWP Required

  Yes

  No

  N/A

• List EWP required

• Enter description of risk & control measures

• Add Photos

  Media

Access & Egress

• Access & Egress

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Electricity

• Electricity

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Isolation Permit Required

  Yes

  No

  N/A

• Enter description of risk & control measures

• Add Photos

  Media

Ground Conditions

• Uneven / Slips, Trips & Falls

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Hazardous Materials

• Hazardous Gases

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Asbestos

• Asbestos

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Vehicle & Pedestrian movement

• Vehicular & People movement

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Dust & Airborne particle's

• Dust & Airborne particle's

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Overhead hazards

• Overhead hazards

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

Manual handling

• Manual handling

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

Fire / Explosion

• Fire / Explosion

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Noise

• Noise

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Buried/Covered services

• Buried/Covered services

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of risk & control measures

• Add Photos

  Media

Lone worker

• Lone worker

  Safe

  At Risk

  N/A

• Likelihood of occurrence

  Likely to occur

  May occur

  Not likely to occur

• Severity

  Fatality/ Disability

  Medical treatment

  Incident report only

• Risk rating

  High

  Medium

  Low

• Enter description of control measures

Completion

• Observations and recommendations

• Assessment completed

  Date

• Assessment Report Sent to

  Select

• EPSM representative

  Sign