Risk Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Life Safety

• Will the fire alarm and/or detection system be inoperable or impaired? ( If yes Fill out interim Life Safety Measures )

  Yes

  No

• Will emergency exits be obstructed? ( If yes fill out Interim Life Safety Measures )

  Yes

  No

• Will repairs or maintenance be over occupied work areas? ( if yes fill out Interim Life Safety Measures )

  Yes

  No

• Will normal traffic need to be rerouted? ( If yes fill out Interim Life Safety Measures )

  Yes

  No

• Will their be work above the ceiling? ( If yes fill out Facilities Management Work Permit )

  Yes

  No

Infection Control

• Will air quality be affected temperature,moisture,dust,required air changes? (If yes give description of what will be done to maintain air quality )

  Yes

  No

• Will work area need to be concealed due to dust or infection control? ( If yes give description of how area will be concealed )

  Yes

  No

• Will noise levels be affected in the area? ( If yes give description of what will be done to minimize noise levels )

  Yes

  No

Safety

• Is personal protective equipment available in work area?

  Yes

  No

  N/A

• Has everyone around the work area been notified of work to be performed?

  Yes

  No

  N/A

• Will their be any Hot Work? ( If yes have Facilities Management fill out hot work permit )

  Yes

  No

• Is fire extinguisher available in work area?

  Safe

  At Risk

  N/A

Risk Assessment Results

• Select date

  Date

• Add signature

  Sign