Workplace Hazard Assessment Form

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

• Nature of work

• Enter work process or flow

Process

• Work Process

• Category of hazard identified

  Select Physical Chemical Biological Ergonomic Environmental Safety Other

  • Physical
  • Chemical
  • Biological
  • Ergonomic
  • Environmental
  • Safety
  • Other

• other category

• List hazards identified

• Severity

  0

  2

  4

  6

• 

• Number of persons who may be exposed to or have contact with the hazard

  Few

  Moderate

  Many

• Number of times persons may be exposed to or have contact with the hazard

  Less than daily

  Few times per day

  Many times per day

• Number of times persons may be exposed to or have contact with the hazard

  Less than daily

  Few times per day

  Many times per day

• Number of times persons may be exposed to or have contact with the hazard

  Less than daily

  Few times per day

  Many times per day

• 

• Probability

  -1

  0

  1

• 

• Significance

  Low

  Medium

  High

• Is training required?

  Yes

  No

  N/A

• Are the controls in place adequate?

  Yes

  No

  N/A

Recommendations

• Write recommendations for safety planning and purposes

Completion

• Full Name and Signature of Inspector

  Sign