Workplace Violence Risk Assessment Form
Workplace Violence Risk Assessment Form · FORM-31127
Guidance Sheet for Workplace Violence Risk Assessment Form
Stage 1. Introduction.
Stage 2. Hazard Identification.
Stage 3. Risk Control.
Stage 4. Monitor and review.
Summary - Key Outcomes:
Workplace Violence Risk Assessment – Part 1
- Risk Assessment No.
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- Risk Assessment Approved by: Name/Signature
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- Company Name
- [Company]
- Address
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- ABN
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- Contact Name
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- Position
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- Phone No.
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- Job Title
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- Date
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Workplace Details
- Location
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- No. of workers at the workplace
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- Specify (remote work)
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- Specify (isolated work)
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- Specify (outdoors)
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- Specify (indoors)
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- Specify (off-site)
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- Assessor Name / Signature
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- Assessor Job Title
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- Assessor Date
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- Names of workers consulted with during development of this Risk Assessment / Signature/s
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- Job Title/s
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- Workers Date
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- Person Responsible for ensuring compliance with Risk Assessment / Signature
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- Person Responsible Job Title
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- Person Responsible Date
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| 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.
Hierarchy of Controls
Exposure To Violence Hazard Factors | Control measures in place | Person/s Responsible | ||||
|---|---|---|---|---|---|---|
Prior Incidents | ||||||
Staff Management | ||||||
Workplace Violence Risk Assessment – Part 2
- Monitor & Review: Person/s Responsible
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- Monitor & Review: Signature/s & Date
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Review Record
Review Date | Review conducted by | Signature/s | Next review due |
|---|---|---|---|
Workplace Violence Risk Assessment – Part 3
Workplace Violence Risk Assessment – Part 3
This Risk Assessment has been developed in consultation and cooperation with workers and the Organisation. I have read the above Risk Assessment, and I understand its contents. I confirm that I have the skills and training, including relevant certification, to conduct the task as described. I agree to comply with safety requirements within this Risk Assessment, including risk control measures, safe work instructions and management direction.
| Worker’s name | Job role / positione.g. supervisor, worker, trainee | Company | Licences, competencies & qualificationsType / descriptionClassNumber | Date | Signature |
|---|---|---|---|---|---|
| - | - | - | - | - | - |
| - | - | - | - | - | - |
| - | - | - | - | - | - |
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Workplace Violence Risk Assessment Form · FORM-31127
