Road Vehicle Risk Assessment Form
फारम - Version 2
Road Vehicle Risk Assessment Form · FORM-31202
- Risk Assessment No.
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- Risk Assessment Approved by:
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- Company Name:
- [Company]
- Address:
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- Name/Signature:
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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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- Location:
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- No. of workers at the workplace:
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- Assessor Name/Signature:
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- Assessor Job Title:
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- Specify:
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- Specify:
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- Specify:
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- Specify:
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- Names of workers consulted with during the development of this Risk Assessment/Signature/s:
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- Job Title/s:
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- Date:
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- Person Responsible for ensuring compliance with Risk Assessment/Signature:
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- Job Title:
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- 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.
- Scope of Risk Assessment
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- Description of Job/Task
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Hazards and control measures
Road hazard – speed/mechanical: Can the workers' risk levels be increased or affected?
Road hazard - environmental conditions: Can the workers' fatigue levels be increased or affected by the environmental conditions at the workplace?
Road hazard: Can the workers' risk levels be increased or affected by road hazards?
Worker factors: Can the workers' risk levels be increased or affected by worker factors?
Loading and unloading: Can the drivers potential to speed be increased or affected by loading and unloading schedules?
Information and instruction: Can the drivers potential to speed be decreased by improved training, information and communication?
Mass management: Can an overloaded vehicle impact road performance, mechanical safety and/or damage infrastructure?
Dimension management: Could an over-dimension load affect road safety, mechanical integrity and/or cause harm to people or infrastructure?
Load restraint: Could a poorly restrained load affect road safety, mechanical integrity and/or cause harm to people or infrastructure?
Vehicle maintenance: Could vehicle maintenance practices affect road safety, mechanical integrity and/or cause harm to people or infrastructure?
Driver actions: Could driver actions cause an accident or harm to themselves or others?
Slips, trips and falls – Is there potential for a slip, trip or fall to occur?
Falling objects - Is there potential for falling objects to cause damage or harm to people?
Traffic management - Can site traffic management impact health and safety and/or damage infrastructure?
Other hazard – other:
Monitor and review
- Person/s Responsible:
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- Signature/s and Date:
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Name: | Initial: | Date: | |
|---|---|---|---|
Worker Sign-Off & Acknowledgement
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 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 Personal Protective Equipment described.
| Worker’s name | Job role / positione.g. supervisor, worker, trainee | Company | Date | Signature |
|---|---|---|---|---|
| - | - | - | - | - |
| - | - | - | - | - |
| - | - | - | - | - |
यसको मार्गदर्शन र नमुना प्रविष्टिहरू लक गरिएका छन्
फारमको बनावट कस्तो छ तपाईं देख्न सक्नुहुन्छ। जुनसुकै डिभाइसमा भर्न, प्रिन्ट गर्न वा आफ्नो बनाउन यो लिनुहोस्।
Road Vehicle Risk Assessment Form · FORM-31202
