Safety, Health and Environment Risk Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1. Work / Task / Operation / Activity covered:

Significant Hazards: (The potential to cause harm)

• Consider the severity of the outcome and the hazard occurring to determine the risk rating: H = High / M = Medium / L = Low / I = Insignificant

• Hazard 1

  H

  M

  L

  I

• Hazard 2

  H

  M

  L

  I

• Hazard 3

  H

  M

  L

  I

• Hazard 4

  H

  M

  L

  I

• Hazard 5

  H

  M

  L

  I

• Hazard 6

  H

  M

  L

  I

• Hazard 7

  H

  M

  L

  I

• Hazard 8

  H

  M

  L

  I

• Hazard 9

  H

  M

  L

  I

• Hazard 10

  H

  M

  L

  I

Who by be affected:

• Consider the effects of the hazards in any person who may become exposed to them.
  How many could be affected?

• Employees?

  Yes

  No

• General Public

  Yes

  No

• Subcontractors

  Yes

  No

• Official Visitors

  Yes

  No

• Others

  Yes

  No

Control Measures:

• Control measure 1

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 2

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 3

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 4

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 5

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 6

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 7

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 8

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 9

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

• Control measure 10

• In place?

  Yes

  No

  N/A

• Date for intended action:

  Date

Final Risk Evaluation with Control Measures in Place

• H

  M

  L

  I

Assessor Details

• Completed by:

  Sign

• Date for review (if applicable)

  Date