Risk Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Background information

• Background information

Risk Assessment

Hazard

• Hazard

• Media

  Media

• People Affected

  Select Staff Patients Contractors

  • Staff
  • Patients
  • Contractors

• Likelihood

• Consequence

• Risk Rating

  1-3 Low risk

  4-6 Moderate risk

  8-12 High risk

  15-25 Extreme risk

• Controls

• Are the controls adequate!

  Yes

  No

  Yes - Room for improvement

Action Plan

Action plan

• Action title

• Description of action

• Responsibility

• By when

  Date

• Add media

  Media