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 |
|---|---|---|---|---|
| - | - | - | - | - |
| - | - | - | - | - |
| - | - | - | - | - |
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Chemical Risk Assessment Form · FORM-30113