Sample - Risk Assessment Template

• Conducted on

  Date

• Prepared by

• Location
  Address

Overview

• Description of procedure, task or worksite being assessed

Risk Matrix and Hierarchy of Controls

• Risk Matrix Reference:

• Hierarchy of Controls Reference:

Hazard Register

Hazard

• Description of hazard

• Photo of hazard

  Media

Risk Rating

• Consequences

  Fatality

  Major Injuries

  Minor Injuries

  Negligible Injuries

• Likelihood

  Very Likely

  Likely

  Unlikely

  Highly Unlikely

• Risk Rating (refer risk matrix above)

  High

  Medium

  Low

• Comments/ observations

Controls

• Select control measures

  Select Elimination Substitution Engineering Controls Administrative Controls PPE Other

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

• Enter other

• Explanation of controls

  Select Elimination Substitution Engineering Controls Administrative Controls PPE Other

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

Completion

• Recommendations

• Signature

  Sign