Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Assessment Number

  • Department

  • Departmental Manager

  • Date Prepared

  • Review Date

  • Describe the work activity undertaken and the place or site this is taking place (if different from above)

HAZARD IDENTIFICATION AND ASSESSMENT OF RISK

  • Use this list and add any other items which are unique to this task or work area. Step back and consider if any other hazards involve the managers, staff and where necessary the safety department, when deciding what is to be included.

  • Hazard 1:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 2:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 3:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 4:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 5:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 6:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 7:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 8:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 9:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

  • Hazard 10:

  • LIKELIHOOD

  • SEVERITY

  • What Category is this Risk

  • Please Specify:

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Further Actions Required?

AFFECTED PERSONS

  • The presence of any of the following groups may affect the level of Risk (due to vulnerability, lack of knowledge etc) associated with the hazards identified above. Additional safety controls maybe necessary. Include all the groups relevant to this Risk assessment.

  • Affected Group 1:

  • Please specify how they are affected

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Affected Group 2:

  • Please specify how they are affected

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Affected Group 3:

  • Please specify how they are affected

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Affected Group 4:

  • Please specify how they are affected

  • Describe the Existing Control System (to prevent accidents/incidents)

  • Affected Group 5:

  • Please specify how they are affected

  • Describe the Existing Control System (to prevent accidents/incidents)

RISK LEVEL = LIKELIHOOD x SEVERITY

  • SEVERITY

  • LIKELIHOOD Slightly Harmful Harmful Extremely Harmful

  • Highly Unlikely Trivial Risk 1 Tolerable Risk 2 Moderate Risk 3

  • Unlikely Tolerable Risk 2 Moderate Risk 3 Substantial Risk 4

  • Likely Moderate Risk 3 Substantial Risk 4 Intolerable Risk 5

ACTION DEFINITIONS

  • 1. Trivial No Action is required and no documentary records need to be kept

  • 2. Tolerable No additional controls are required. Consideration may be given to a more cost effective solution or improvement that imposes no additional cost burden. Monitoring is required to ensure that the controls are maintained.

  • 3. Moderate Efforts should be made to reduce the risk, but the costs of prevention should be carefully measured and limited. Risk reduction measures should be implemented within a defined time period. Where the moderate risk is associated with extremely harmful consequences, further assessment may be necessary. This is to establish more precisely the likelihood of harm as a basis for determining the need for improved control measures.

  • 4. Substantial Work should not be started or access permitted until the risk has been reduced. Considerable resources may have to be allocated to reduce the risk. Where the risk involves work in progress, urgent action should be taken

  • 5. Intolerable Work should not be started, continued or access permitted until the risk has been reduced to an acceptable level. If it is not possible to reduce the risk even with unlimited resources, work has to remain prohibited

ACTION PLAN

  • Risk (Particularly for High or Medium Risks)

  • Describe any Actions Required

  • Responsible Person

  • Target Completion Date

  • Actual Completion Date

  • What Further Actions Are Required? (Does the Risk Assessment need to be reviewed?)

  • Risk (Particularly for High or Medium Risks)

  • Describe any Actions Required

  • Responsible Person

  • Target Completion Date

  • Actual Completion Date

  • What Further Actions Are Required? (Does the Risk Assessment need to be reviewed?)

  • Risk (Particularly for High or Medium Risks)

  • Describe any Actions Required

  • Responsible Person

  • Target Completion Date

  • Actual Completion Date

  • What Further Actions Are Required? (Does the Risk Assessment need to be reviewed?)

  • Risk (Particularly for High or Medium Risks)

  • Describe any Actions Required

  • Responsible Person

  • Target Completion Date

  • Actual Completion Date

  • What Further Actions Are Required? (Does the Risk Assessment need to be reviewed?)

DEPARTMENT MANAGERS DECLARATION

  • To be signed off ONLY when the Risk Assessment has be completed.

  • Name of Assessor

  • Date

  • Dept/Site

  • Tel/Email

  • THE DEPARTMENT HEAD SHOULD NOW CHOOSE AS APPROPRIATE AND SIGN THE FORM

  • Dept Head Action Plan (where applicable)

  • Signature of Manager

  • Date completed

  • Dept/Site

  • Tel/Email

  • Reviewed by Health and Safety

DISTRIBUTION OF SIGNIFICANT FINDINGS

  • Name

  • Department

  • Name

  • Department

  • Name

  • Department

  • Name

  • Department

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.