Risk Assessment Scope
Date:
*
-
Day
-
Month
Year
at
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2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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Observer Full Name:
*
Subcontractor / Employee
*
Type your position
Site Name & Full Address:
*
Company Name and Address of Hazard
Describe the Activity / Task / Product which presents potential Risk
Hazard Identification & Risk Assessment
Hazard Description ( ie leaking roof )
Risk Description ( i.e slip on floor)
Initial Risk Rating
Proposed Risk Controls ( ie mop floor and place hazard sign)
Type of risk control
Residual Risk Rating
1
2
3
4
Recommended Action Summary
For each proposed risk control, provide a recommended action and allocate a responsible person and time frame in consultation with that person. Completion confirmation is required for each action.
Recommended Actions
Accountable area
Responsible Persons
Target completion Date
Actual completion Date
1
2
3
4
REVIEW
YES
NO
Control Measures have been reviewed and no further risks have been identified
Are further Review required
Manger / supervisor Name:
Manager / supervisors Signature
Record of Subsequent Revies
Review Date
Reviewed by
Description of any changes
Review 1
Review 2
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