Risk Assessment Form
Formulario - Version 6
Risk Assessment Form · FORM-30012
Guide sheet
- Name of Assessor
- —
- Date
- —
- Location
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- Review Date
- —
Hazards Involved | Control Measure | Risk Rating | Person Responsible | Date Completed |
|---|---|---|---|---|
Hierarchy of controls
Risk matrix
Step 1: Determine Likelihood
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 | Action |
|---|---|
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Risk Assessment Form · FORM-30012
