Risk Assessment Template

• Conducted on

  Date

• Enter site name

• Prepared by

• Location
  Address

General

• Enter description of procedure, task or worksite being assessed

Hazards, Risks and Controls

• Click Add Hazard (+) after you have observed and identified a task and associated hazard

Hazard

Hazard

• Activity

• Description of hazards identified

• Photo of hazard (optional)

  Media

• Persons at risk

Initial risk rating

• Initial consequence

  Fatality

  Major Injuries

  Minor Injuries

  Negligible Injuries

• Initial likelihood

  Very Likely

  Likely

  Unlikely

  Highly Unlikely

• Initial risk rating

  High

  Medium

  Low

Controls

• Select control measures

  Select Elimination Substitution Engineering Controls Administrative Controls PPE Other

  • Elimination
  • Substitution
  • Engineering Controls
  • Administrative Controls
  • PPE
  • Other

• Enter other control measures

• Enter description of control measures

Residual risk rating

• Residual consequence

  Fatality

  Major Injuries

  Minor Injuries

  Negligible Injuries

• Residual likelihood

  Very Likely

  Likely

  Unlikely

  Highly Unlikely

• Residual risk rating

  High

  Medium

  Low

References

• Risk Matrix Reference

  

• Hierarchy of Controls Reference

  

Completion & Work Group Sign Off

• Recommendations

• Signature

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