Risk assessment form sample

RISK ASSESSMENT FORM

Introduction : Risk assessment form sample

 

Risk assessment form sample; A Risk Assessment Form is a systematic process to identify potential hazards and evaluate the risks associated with them. The purpose of this form is to assess the likelihood and severity of each identified risk, allowing for appropriate control measures to be implemented. The process helps ensure that workplace health, safety, and operational risks are minimized or controlled.

SECTION 1: GENERAL INFORMATION

1. Project/Activity Title: Provide the title of the project or activity being assessed. Be as specific as possible.
   Example: Office Relocation Project
2. Assessor’s Name: Include the name of the person conducting the assessment.
   Example: Jane Doe
3. Date of Assessment: Insert the date the risk assessment was conducted.
   Example: October 3, 2024
4. Location: Mention the location where the assessment is being carried out.
   Example: Head Office, 5th Avenue, New York
5. Department/Unit: Specify the department or unit for which the assessment is applicable.
   Example: Operations Department
6. Review Date: Specify a date for reviewing the assessment, ensuring the risks are managed on an ongoing basis.
   Example: April 3, 2025

SECTION 2: DESCRIPTION OF WORK/ACTIVITY

Risk assessment form sample

Description of the Task or Activity: In this section, provide a detailed explanation of the task or activity being assessed. Include relevant details like the steps involved, equipment used, and the people performing the task.

Risk assessment form sample

Example: The activity involves relocating office equipment, furniture, and sensitive documents from the current office space to a new location 15 miles away. This includes lifting, handling, transportation, and re-installation. Workers will use hand trucks, moving carts, and company vehicles.

SECTION 3: HAZARD IDENTIFICATION

Risk assessment form sample

 

In this section, list the potential hazards that could arise from the task or activity being assessed. Each hazard should be briefly described. Typical hazards could include physical, chemical, biological, and environmental factors.

Example:

1. Manual Handling Injuries: There is a risk of musculoskeletal injuries from lifting and moving heavy items.
2. Slips, Trips, and Falls: Loose cables, packing materials, and spills may create a tripping hazard.
3. Electrical Hazards: Improper disconnection or reconnection of electrical devices during the move.
4. Vehicle Accidents: Potential for traffic accidents while transporting equipment between locations.
5. Exposure to Hazardous Substances: Risk of exposure to cleaning chemicals used during the office clean-up process.

SECTION 4: RISK ASSESSMENT

Each hazard identified in the previous section must be evaluated in terms of likelihood and severity. The combination of these two factors will provide the overall risk level for each hazard.

Risk Rating Scale:

Here, provide a simple scoring system to evaluate risks. An example of a risk rating matrix is shown below.

• Likelihood: 1 = Rare
  2 = Unlikely
  3 = Possible
  4 = Likely
  5 = Almost Certain
• Severity: 1 = Insignificant
  2 = Minor
  3 = Moderate
  4 = Major
  5 = Catastrophic

Risk Level:

Risk Level = Likelihood x Severity

• Low Risk (1-4): No additional controls needed.
• Medium Risk (5-10): Control measures required.
• High Risk (11-15): Immediate action required.
• Critical Risk (16-25): Activity must cease until risk is reduced.

SECTION 6: CONTROL MEASURES IMPLEMENTATION PLAN

Detail how the control measures identified in the previous section will be implemented. This section also includes roles and responsibilities.

Control Measures:

• Training Programs:

1. 1. • Provide manual handling and lifting training to all staff involved in the move.
      • Conduct training sessions on electrical safety to ensure safe handling of office equipment.

• Site Preparation:

1. 1. • Inspect the workspace for potential hazards (cables, spills, debris) before commencing work.
      • Ensure the floors are clear of obstructions and that packing materials are disposed of properly.

• Vehicle Safety:

1. 1. • Perform maintenance checks on vehicles before the move, checking tires, brakes, and lighting.
      • Develop a transportation plan that includes scheduled breaks for drivers and alternate routes in case of heavy traffic.

• PPE and Equipment Use:

1. • Ensure all employees are supplied with necessary PPE such as gloves, steel-toe boots, and safety goggles, if needed.
   • Regularly inspect the condition of moving equipment like trolleys, ensuring they are in good working order.

Responsible Personnel:

• Project Manager: John Smith (Overall responsibility for ensuring control measures are implemented)
• Safety Officer: Sarah Brown (Oversees training, hazard monitoring, and PPE compliance)
• Drivers: Assigned employees from the logistics team

SECTION 8: EMERGENCY PROCEDURES

This section outlines emergency protocols in case something goes wrong during the task or activity. It should include response strategies for each major risk identified.

• Manual Handling Injuries:

1. 1. • Stop work immediately if a worker is injured while lifting.
      • Apply first aid to any strains or sprains and call for medical assistance if the injury is serious.
      • Review manual handling procedures to prevent future injuries.

• Slips, Trips, and Falls:

1. 1. • Remove workers from the affected area immediately.
      • If a fall occurs, assess the injured person, provide first aid, and call for medical assistance if necessary.
      • Ensure spillages are promptly cleaned and hazards marked.

• Electrical Hazards:

1. 1. • If there’s an electrical incident, disconnect the power supply immediately if it’s safe to do so.
      • Provide first aid for any electrical burns or injuries, and contact emergency services.

• Vehicle Accidents:

1. • In the event of an accident during transportation, drivers should immediately contact emergency services.
   • Follow company protocol for reporting the incident and assist any injured individuals.

SECTION 9: MONITORING AND REVIEW

This section provides details on how the effectiveness of the risk assessment and control measures will be monitored over time.

Monitoring Plan:

• Weekly safety audits will be carried out by the Safety Officer during the moving period to ensure compliance with control measures.
• Any changes to the work plan (e.g., new equipment or additional personnel) will require a re-assessment of risks.

Review Process:

• The risk assessment will be formally reviewed six months after completion of the move, or sooner if any incidents occur.
• Any lessons learned will be documented and integrated into future assessments.

SECTION 10: SIGN-OFF AND APPROVAL

Assessor Name and Signature:
*The name

Hazards Identified:

1. Manual handling injuries
2. Slips, trips, and falls
3. Electrical hazards
4. Vehicle accidents

Control Measures:

• Provide lifting training and use equipment.
• Keep work areas clear.
• Disconnect/reconnect electricals safely.
• Ensure vehicles are inspected and driven by licensed personnel.

Risk Rating:

• Manual handling injuries: High (12)
• Slips, trips, and falls: High (12)
• Electrical hazards: Medium (10)
• Vehicle accidents: High (15)

Control Measures:

• Provide lifting training and use trolleys or carts.
• Maintain a clutter-free workspace.
• Have qualified personnel manage electrical equipment.
• Ensure drivers are licensed, vehicles are checked, and routes are planned.

 

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