Title Page

  • Site conducted

  • Prepared by

  • Location

Section 1

  • Date of Assessment:

  • Name or Description of Task:

  • Reason for review:

  • Please tick the post incident outcome:

  • Sign off of particpants
  • Sign off review completed by (Name and Sign)

Section 2 - Reference information

  • Use the chart below to refer for the hazard prompts, example images and smaple control measures

  • Section 3: Completeion of the assessment
  • Description: Provide a description of the task

  • Hazard Prompt : Use the Chart provided in section 2 .

  • undefined

  • New and/or Additonal controls (see sample controls Measures)

  • Provide a breif description of the hazard

  • What current control Measures are being used?

  • What addtional controls should be considered?

  • Provide a breif description of the of the hazard .

  • Provide details of the controls currently used

  • What additonal controls should be considered?

  • Provide a breif description of the hazard:

  • What control measures are currently being used (please provide a breif description)

  • What additional controls should be considered?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.