Title Page
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Prepared by
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Location
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Date of Assessment
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Proposed Review Date
Company Details
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Company Name:
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Address:
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Contact Name:
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Tel No:
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Email:
Assessors Details
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Name of Assessor:
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Tel No.
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Email:
Introduction
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General Information and brief description of activities covered by this assessment:
Assessment
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Hazard
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Hazard Identified
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Who Might be Harmed and How?
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Existing Measures to control risk and general comments
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Risk Rating (Consider Likelihood and Severity)
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Risk Adequately Controlled?
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See Action Plan at the end
Action Plan
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Are Further Actions required?
Action
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Hazard Reference Number
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Further Action Required
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Action by whom
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Implementation Date
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Comments