Information
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Crew/Team name - Road Name
Risk Assessment Form
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Form No. CO FRM 001
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Project/Program/WRR/CSR
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Work Site Address
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Date
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Safe Work Method Statement Number
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Crew
ACTIVITY
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List of activities
- Inspecting Assets
- Walking
- Standing
- Watching
- Driving
- Carrying items (e.g. iPad, paper, measurement instruments etc.)
- Moving around on the road
- Other
PERSONAL PROTECTIVE EQUIPMENTS REQUIRED
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List of PPE
- Footware
- High Visible Vest
- Helmet
- Eyewear
- Gloves
- Hearing
- Dust Mask
- Other (e.g. respirator, reflective overall etc)
RISK MATRIX
POSSIBLE HAZARDS
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To be filled in if there are any additional risks not covered by the Safe Work Method Statement
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1. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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2. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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3. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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4. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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5. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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6. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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7. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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8. Hazard
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Description of risk with associated hazard
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Consequence
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Likelihood
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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9. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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10. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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More Hazards?
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11. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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12. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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13. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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14. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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15. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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16. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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17. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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18. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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19. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
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20. Hazard
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Description of risk with associated hazard
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Likelihood
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Consequence
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Risk Score
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Current control measures in place?
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Risk Score with controls?
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Additional control measures required?
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Describe additional control
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Risk Score with additional controls?
ENVIRONMENTAL RISK ASSESSMENT
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Site Assessment to be filled in for each worksite
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Site Runoff/Siltation: Is drainage from the work area likely to enter a swamp or watercourse directly?
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Controls
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Dust/Noise/Air Pollution: Can work carried out create large quantities of airborne dust, excessive noise or emissions?
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Controls
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Fuel and Oil spillage: Are there measures in place to control fuel and oil spills?
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Controls
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Erosion: Is erosion likely to occur as a result of these works?
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Controls
STAFF DETAILS
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Prepared By
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Staff should sign as having understood the Safe Work Method Statement/ Risk Assessment/ Site Safety Rules & WH&S Policy
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1. Staff Signature
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1. Staff Signature
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2. Staff Signature
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1. Staff Signature
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2. Staff Signature
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3. Staff Signature
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1. Staff Signature
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2. Staff Signature
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3. Staff Signature
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4. Staff Signature
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1. Staff Signature
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2. Staff Signature
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3. Staff Signature
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4. Staff Signature
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5. Staff Signature
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1. Staff Signature
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2. Staff Signature
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3. Staff Signature
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4. Staff Signature
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5. Staff Signature
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6. Staff Signature
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1. Staff Signature
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2. Staff Signature
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3. Staff Signature
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4. Staff Signature
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5. Staff Signature
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6. Staff Signature
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7. Staff Signature
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1. Staff Signature
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2. Staff Signature
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3. Staff Signature
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4. Staff Signature
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5. Staff Signature
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6. Staff Signature
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7. Staff Signature
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8. Staff Signature
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1. Staff Signature
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2. Staff Signature
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3. Staff Signature
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4. Staff Signature
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5. Staff Signature
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6. Staff Signature
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7. Staff Signature
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8. Staff Signature
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9. Staff Signature
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1. Staff Signature
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2. Staff Signature
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3. Staff Signature
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4. Staff Signature
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5. Staff Signature
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6. Staff Signature
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7. Staff Signature
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8. Staff Signature
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9. Staff Signature
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10. Staff Signature
