COSHH Risk Assessment Form

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

General Information

• Department

• Persons involved in COSHH Assessment

• People at Risk

  Select Employees Students Vulnerable persons Others

  • Employees
  • Students
  • Vulnerable persons
  • Others

• other people at risk

Hazard Identification

• Add + activity or work process

Process

• undefined

• How long will it take?

• How often will it be repeated?

• How much substance is used?

• Locaton of the process or work being carried out

• 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 form the substance takes

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

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

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

  Select Inhalation Skin Eyes Ingestion Other state

  • Inhalation
  • Skin
  • Eyes
  • Ingestion
  • Other state

• Workplace Exposure Limits (WELs)

• Long-term exposure level

• Short-term exposure level

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

Control Measures

• List below control measures eg extraction, ventilation, supervision, include additonal controls for vulnerable persons where necessary

• Is health surveillance or monitoring required? (remember health surveillance may be required for vulnerable persons eg pregnant/young workers those with asthma, dermatitis etc)

  Yes

  No

  N/A

Personal Protective Equipment

• Identify type and specification

  Select Dust mask Respirator Gloves Footwear Visor Goggles Overalls Other

  • Dust mask
  • Respirator
  • Gloves
  • Footwear
  • Visor
  • Goggles
  • Overalls
  • Other

• Other PPE

• Provide standard measures for each PPE required

First Aid Measures

• Write first measures when in contact with these chemicals

Storage and Disposal of Substances and Contaminated Containers

• How do you store these substances?

• Means of Disposing Hazardous Waste

  Select Skip Return to Depot Return to Supplier Other

  • Skip
  • Return to Depot
  • Return to Supplier
  • Other

• Other means

Summary

• Is the exposure adequately controlled?

  Yes

  No

  N/A

• Risk rating after following control measures

  HIGH

  MEDIUM

  LOW

Completion

• Full Name and Signature of the Inspector

  Sign