Dust Risk Assessment Template

• Site

• Date and Time of Assessment

  Date

• Safety Officer (Full Name)

• Location
  Address

Overview

• Description of procedure, task or worksite being assessed

Risk Matrix and Hierarchy of Controls

• Risk Matrix Reference:

  

• Hierarchy of Controls Reference:

  

Hazard Register

Hazard

• Description of hazard

• Photo of hazard (optional)

  Media

• Type of Dust

  Inhalable dust

  Thoracic dust

  Respirable dust

Risk Rating

• Consequences

  Fatality

  Major Injuries

  Minor Injuries

  Negligible Injuries

• Likelihood

  Very Likely

  Likely

  Unlikely

  Highly Unlikely

• Risk Rating (refer risk matrix above)

  High

  Medium

  Low

Controls

• Select control measures

  Select Elimination Substitution Engineering Controls Administrative Controls PPE Other

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

• Enter other

• Description of support measures

Completion

• Recommendations

• Name and Signature of Safety Officer

  Sign