Title Page

  • Assessment / Site Reference Number

  • Ref number

  • Assessment date

  • Activity / Item / Area

  • Poeple At Risk

  • Responsible Person

  • Use of premises or site works taking place

  • Assessor

  • Review Date

  • Monitoring Frequency

  • Authorised by

Hazard Table

Sources of Ignition

  • A. Smokers - Cigarettes, Matches, Lighters

  • B. Naked flames - gas, open flame

  • C. Electric, gas, cable strike

  • D. Hot processes, welding, cutting, grinding

  • E. Cooking equipment

  • F. Lighting

  • G. Arson

  • H. Faulty / misused equipment / poor maintenance

  • I. Reactive chemicals

Sources of Fuel

  • J. Textiles / clothing

  • K. Flammable liquids / solvents

  • L. Plastics / rubber

  • M. Waste materials

  • N. Flammable gases

  • O. Combustible construction materials - walls, floors, doors

  • P. Combustible storage materials

  • Q. Packaging materials

Sources of Oxygen

  • R. Natural ventilation through doors / windows

  • S. Explosion

  • T. Oxidising chemicals

  • U. Oxygen cylinders

Additional Sources

  • V

  • Degree of Risk

  • W

  • Degree of Risk

  • X

  • Degree of Risk

  • Y

  • Degree of Risk

  • Z

  • Degree of Risk

Potential for Fire to Spread

Conduction (Heating Through Materials)

  • AA. Through Arcing High Voltage Equipment

  • BB. Through piping / services

  • CC. Doors (if not fire doors)

  • DD. Hoarding

Convection (Hot Air Movement)

  • EE. Stairs

  • FF. Shafts / service ducts

  • GG. Windows

  • HH. Doors (open, wedged, not-self closing, damaged)

  • II. Roof voids

Radiation

  • JJ. Direct heat

Additional Hazards

  • KK

  • Degree of Risk

  • LL

  • Degree of Risk

  • MM

  • Degree of Risk

  • NN

  • Degree of Risk

  • OO

  • Degree of Risk

Monitoring Information

  • Person carrying out the monitoring (print name)

  • Department / Location

  • Checked by

  • Date

Control Measures

  • Fire Fighting equipment - state Number, Types and Locations

  • How many

  • Location(s)

  • How Many

  • Location(s)

  • How Many

  • Location(s)

  • How Many

  • Location(s)

  • How Many

  • Location(s)

  • Fire Detection and Warning System - State Numbers, Types and Locations

  • How Many

  • Location(s)

  • How Many

  • Location(s)

  • How Many

  • Location(s)

  • Notices/ Records/ Procedures

  • Escape Routes

  • Maintenance and Testing of Equipment

  • Building Design – Features of Escape Routes

  • Housekeeping / Storage of Waste and Materials

  • Additional Control Measures

Further Actions Required

  • 1.Action

  • Responsibility

  • Date

  • Action

  • Responsibility

  • Date

  • Action

  • Responsibility

  • Date

  • Action

  • Responsibility

  • Date

  • Action

  • Responsibility

  • Date

  • Action

  • Responsibility

  • Date

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.