Title Page

  • Client / Site

  • Location
  • Conducted on

  • Prepared by

Hazard Identification

  • Click + to add hazards identified
    Note: *If the substance has a R45 or R49 risk phrase or a H350 or H350i hazard statement, it must also be registered on your personal carcinogen return (at Occupational Health) where exposure is not adequately controlled.

  • Substance
  • Name of Chemical

  • What will the chemical be used for?

  • Who may be exposed?

  • Hazardous Properties (Provide details of how the substance could cause harm, e.g. harmful by inhalation, skin contact, flammable, carcinogen, allergen, etc)

  • Quantity (Indicate how much of the substance will be used)

  • Workplace Exposure Limits (WELs)

  • Emergency procedures

  • What are the emergency procedures needed?

Methods of Prevention or Control of Exposure

  • Engineering controls required

  • other engineering control needed

  • Access control

  • other access control needed

  • Special procedures

  • other special procedure needed

  • Approved PPE

  • Other approved PPE used

  • Disposal Procedures Note: (Give details of waste disposal procedure to be used)

  • Are chemicals with risk phrases R50-R59 or hazard statements H400 – H413 (environmental hazards) involved?

  • Training Requirements Note: (List any specialised training requirements before work can begin)

  • Handling and Storage Requirements (Note any special requirements e.g. ventilation, chemical incompatibility, flash point, etc)

Assessment of Risk Using Controls Detailed Above

  • Are the hazards/risks suitably controlled, using the control measures detailed above?

  • state the further actions required, e.g. Requirement for a standard operating procedure (SOP), etc

Authorization by Employer/Supervisor

  • I confirm that I have considered and understand the chemical to be used and the associated hazards. I am satisfied that all of the hazards have been identified and that the control measures to be followed will reduce the risks to as low a level as reasonably practicable.

  • Full Name and Signature of Inspector

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.