Hazardous Substance Risk Assessment Form
Chemical Risk Assessment Form · FORM-30113
Hazardous substance risk assessment form guidance sheet
Stage 1. Introduction
Stage 2. Hazard Identification.
Stage 3. Risk Rating
Stage 4. Risk Control
Risk assessment matrix
Likelihood | Criteria | Description |
|---|---|---|
Level of effect | Example of each level |
|---|---|
| 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.
Score | Action |
|---|---|
Hierarchy of controls
Risk assessment
- Name of assessor
- —
- Assessor signature
- —
- Assessor job title
- —
- Assessor date
- —
- Approved by
- —
- Approved by signature
- —
- Approved by job title
- —
- Approved by date
- —
Name | Signature | Date |
|---|---|---|
Hazardous substance details
- Hazardous Substance Name
- —
- Common Name
- —
- Container size
- —
- Maximum Qty to be stored
- —
- Supplier (Name, contact details)
- —
- M/SDS Issued by
- —
- U.N Number
- —
- CAS Number
- —
- M/SDS Issue Date
- —
Safety information
Activity
Name | Initial | Date | |
|---|---|---|---|
Worker sign-off
This risk assessment has been developed in consultation and cooperation with workers and relevant Organisation. I have read the above risk assessment, and I understand its contents. I confirm that I have the skills and training, including appropriate 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 PPE.
| Worker’s name | Job role / positione.g. supervisor, worker, trainee | Licences, competencies & qualificationsType / descriptionClassNumber | Date | Signature |
|---|---|---|---|---|
| - | - | - | - | - |
| - | - | - | - | - |
| - | - | - | - | - |
इसका मार्गदर्शन और उदाहरण वाली एंट्री लॉक हैं
आप देख सकते हैं कि फ़ॉर्म कैसे बना है। इसे लें और किसी भी डिवाइस पर भरें, प्रिंट करें, या अपने हिसाब से बदलें।
Chemical Risk Assessment Form · FORM-30113