H & S Risk Assessment and Control Form

BA/BSD/Project: Risk Assessment by: Verification by:

Location: Date: Sign: Date: Sign:
SECTION I: RISK ASSESSMENT

Sr. No. Identified Hazard Consequence (C) Likelihood (L) Assessed Risk = L x C
Descriptor Rating Descriptor Rating

Guidelines for Risk Assessment

Measurement of Consequence Measurement of Likelihood Assesed Risk
Descriptor Rating Description Descriptor Rating Description Level Rating Description
Will certainly occur in most of Stop the activity. Immediate action required;
Fatal 5 Death Very Likely 5 Etreme 18 - 25
circumstances notify Supervisor, I/C Site HSE
Extensive injuries with lost time injury > 5 Will probably occur in most Immediate action required, notify
Major Injury 4 Likely 4 High 12 - 18
days circumstances Supervisor and I/C Site HSE

Requires medical treatment with lost time

Minor Injury 3 Occasionally 3 Might occur at sometime Moderate 6 - 12 Remedial action required
injury 1-5 days

First aid treatment where medical May occur in exceptional Remedial action required to minimize
First Aid 2 Unlikely 2 Low 1-6
treatment is not required circumstances injury; Supervisor attention needed
Incidents that do not require medical Will not occur in any
Negligible 1 Highly Unlikely 1
treatment; property damage circumstances
 H & S Risk Assessment and Control Form

SECTION II: RISK CONTROL

Actual
Hazard Planned Reason in case of
Control Measures Responsibility Completio Remarks
No. Target Date Delay
n Date

Name Signature

Verification By:____________________ _____________________________

I/C Site HSE I/C / SM / PM