CoR Fatigue Risk Assessment Form
Form - 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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Its guidance and example entries are locked
You can see how the form is laid out. Get it to fill in on any device, print it, or make it your own.
CoR Fatigue Risk Assessment Form · FORM-31662
