• WORK ACTIVITY / ITEM BEING ASSESSED:

  • PERSON(S) AT RISK: (Person affected by activity)

  • HAZARDS IDENTIFIED:

  • OTHER APPLICABLE RISKS:

  • PROPERTY AT RISK: (Equipment / personal belongings etc.)

  • PROBLEMS IDENTIFIED: (That could possibly affect the risk assessment I.e. weather)

  • CURRENT CONTROL MEASURES:

  • SEVERITY SCORE:

  • LIKELIHOOD SCORE:

  • TOTAL = SEVERITY X LIKELIHOOD: Before controls

  • NEW CONTROL MEASURES:

  • SEVERITY SCORE: CONTROLLED

  • LIKELIHOOD SCORE: CONTROLLED

  • TOTAL = SEVERITY X LIKELIHOOD:

  • SUPPORTING MEDIA - CONTROLLED

  • ADDITIONAL NOTES:

  • REVIEW DATE:

  • Signature of assessor:

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