SAFETY RISK ASSESSMENT

• Document No.

• Audit Title

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Associate

• Department Manager

• Primary Contact

Section A - Risk Assessment Demographics

• Select date

  Date

• Entity

  14

  Medical Center

  18

  Restorative

  Medical Group of Carolina's

• Unit / Area

• Division

Section B - Identify the HAZARD & Assessing the Risk

• Needles/Sharps

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• TB Exposure

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Chemical Exposure<br>

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Laser

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Workplace Violence

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Blood/Fluid Exposure

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Lifting patients

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Lifting Material

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Theft

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Patient Falls

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Process Change recommended

  Additional Training Required

  PPE Assessment Required

  Policy Amendment needed.

  No Action Needed

• Employee Falls

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Electrical

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Asbestos

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Radiation

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Elopement

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Power Tools

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Overhead tasks

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Driver Safety

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Burns / thermal exposure

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Ergonomics<br>

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Fire

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Gas / Vapor / Fume

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

• Weather impact

  Virtually No Risk

  MR

  Mod

  HR

  SR

• Analytical /Actions

  Select Process Change recommended Additional Training Required PPE Assessment Required Policy Amendment needed. No Action Needed

  • Process Change recommended
  • Additional Training Required
  • PPE Assessment Required
  • Policy Amendment needed.
  • No Action Needed

Section C- Documentation

• Photos

  Media

• Corrective Action Plan

Section D - Validation

• Safety Officer Signature

  Sign

• Department Manager Signature

  Sign

Section E - Communication

• Forward to

  Select EHS Committee Risk Management Security Admin Infection Prevention Facilities Legal

  • EHS Committee
  • Risk Management
  • Security
  • Admin
  • Infection Prevention
  • Facilities
  • Legal