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