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.
- —
- Risk Assessment Approved by: Name/Signature
- —
- Company Name
- [Company]
- Address
- —
- ABN
- —
- Contact Name
- —
- Position
- —
- Phone No.
- —
- Job Title
- —
- Date
- —
Workplace Details
- Location
- —
- No. of workers at the workplace
- —
- Specify (remote work)
- —
- Specify (isolated work)
- —
- Specify (outdoors)
- —
- Specify (indoors)
- —
- Specify (off-site)
- —
- Assessor Name / Signature
- —
- Assessor Job Title
- —
- Assessor Date
- —
- Names of workers consulted with during development of this Risk Assessment / Signature/s
- —
- Job Title/s
- —
- Workers Date
- —
- Person Responsible for ensuring compliance with Risk Assessment / Signature
- —
- Person Responsible Job Title
- —
- Person Responsible Date
- —
| 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
- —
- Monitor & Review: Signature/s & Date
- —
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 |
|---|---|---|---|---|---|
| - | - | - | - | - | - |
| - | - | - | - | - | - |
| - | - | - | - | - | - |
Phần hướng dẫn và ví dụ điền mẫu đã bị khóa
Bạn có thể xem bố cục của biểu mẫu. Lấy biểu mẫu để điền trên bất kỳ thiết bị nào, in ra, hoặc chỉnh thành của riêng bạn.
Workplace Violence Risk Assessment Form · FORM-31127
