CoR Fatigue Risk Assessment Form
نموذج تعبئة - Version 1
CoR Fatigue Risk Assessment Form · FORM-31662
- Risk Assessment No.
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- Location
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- No. of workers at the workplace
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- Company name
- [Company]
- Address
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- Contact Name
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- Position
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- Phone No.
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- Overnight: specify
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- Shift work: specify
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- Remote work: specify
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- Isolated work: specify
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Step 1: Determine Likelihood
Likelihood | Criteria | Description |
|---|---|---|
Step 2: Determine Consequence
Level of Effect | Example of each level |
|---|---|
Step 3: Determine the risk score
| Consequence → | |||||
|---|---|---|---|---|---|
| Likelihood ↑ | InsignificantNo effect, or so minor that the effect is acceptable | MinorMinor first aid treatment, minimal business disruption, minimal environmental effect | ModerateSerious injuries, medium business interruption, medium environmental impact | MajorExtensive injuries or fatality, significant business interruption, environmental harm, prosecution | CatastrophicMultiple permanent disabilities or fatalities, business failure, substantial environmental harm, prosecution or imprisonment |
| Almost certainExpected in most circumstances | 2 M2 Moderate | 2 M2 Moderate | 3 H3 High | 4 A4 Acute | 4 A4 Acute |
| LikelyWill probably occur in most circumstances | 2 M2 Moderate | 2 M2 Moderate | 3 H3 High | 4 A4 Acute | 4 A4 Acute |
| PossibleCould possibly occur at some time | 1 L1 Low | 2 M2 Moderate | 2 M2 Moderate | 3 H3 High | 4 A4 Acute |
| UnlikelyUnlikely but possible | 1 L1 Low | 1 L1 Low | 2 M2 Moderate | 3 H3 High | 4 A4 Acute |
| RareHighly unlikely to occur | 1 L1 Low | 1 L1 Low | 2 M2 Moderate | 2 M2 Moderate | 3 H3 High |
- 1 L1 LowRecord and monitor. Proceed with work, and review the risks regularly.
- 2 M2 ModerateMaintain control measures. Be cautious when working, and monitor and review regularly.
- 3 H3 HighReview before commencing work. Introduce new controls or maintain high-level controls to lower the risk level, and monitor the controls frequently.
- 4 A4 AcuteDo not proceed until the risk level is reduced. Immediately introduce high-level controls, and re-assess before proceeding.
Step 4: Record risk score on the worksheet
- Name of Assessor
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- Signature:
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- Job Title:
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- Date:
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- Names of people consulted with during development of this Risk Assessment
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- Signature/s:
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- Job Title:
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- Date:
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- Person Responsible for ensuring compliance with Risk Assessment
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- Signature:
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- Job Title:
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- Date:
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- Risk Assessment Approved by
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- Signature:
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- Job Title:
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- Date:
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Monitor and Review
- Person Responsible
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Name | Initial | Date | |
|---|---|---|---|
Work activity
Symptoms of Fatigue
Hazards and control measures
Loading and unloading
- IR
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Vehicles, machinery, equipment
- IR
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Ergonomics
- IR
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Work schedules
- IR
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At-risk worker factors
- IR
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Fitness for work
- IR
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Work hours
- IR
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Shift work (including night work)
- IR
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Amenities
- IR
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Monitoring and measurement
- IR
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Fatigue hazard – other
- IR
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CoR Fatigue Risk Assessment Form · FORM-31662