Task Risk Assessment Form

• Risk Assessment Number:

• Assessment Title (Task Description):

• Initial Assessment

• Revised Assessment

• Assessment Date:

  Date

• Prepared by:

• Tom Murch

• Rick Noble

• James Thomas

• Craig Seekamp

• Jenna Barry

• Robyn Cusick

• Issued:

  Date

• Next Review:

  Date

Part A - Assessment Summary

• Site:

• Department:

• Infrastructure

• Administration

• Corporate & Community Services

• Environmental Health

• Airports

• Building Inspections
• Location:
  Address

• Plant/Project No:

• Other:

• Incident History (Incident Numbers):

• Please insert photo

  Media

Risk Assessment Team

• Please list the risk assessment team

Person

• Name

• James Thomas

• Craig Seekamp

• Rick Noble

• Tom Murch

• Other:

• Position

• Town Maintenance Coordinator

• Construction Coordinator

• Waikerie Works Manager

• Loxton Works Manager

• Other:

• Signed

  Sign

• Date

  Date

Task Risk Assessment sign off

Department Director/Manager

• Name

• Proposed verification date(s):

  Date

• Signed

  Sign

• Date

  Date

OHS Rep/Operator/Employee

• Name

• Signed

  Sign

• Date

  Date

OHS Risk Coordinator

• Name

• Signed

  Sign

• Date

  Date

Part B - Hazard Identification (incorporates part C - risk rating & action plan)

• Can the task be eliminated?

  Yes

  No

  N/A

• Please identify task steps

Task Step

• Task Step

• Hazard Assist

• Plant

• Manual Handling

• Ergonomics

• Substance

• Workplace

• Electrical

• Sips/Trips/falls

• Hazard Description

• Current Controls

• Risk Rating

  Extreme

  High

  Medium

  Low

• Additional Controls Proposed

• Risk Rating

  Extreme

  High

  Medium

  Low

• Responsible Officer

• Due Date

• Risk Rating Matrix