OPERATIONAL RISK ASSESSMENT WORKSHEET Page ______ of ______

1. MISSION: 2. DATE BEGIN: 3. DATE PREPARED: 4. DESIGNATOR NUMBER:

END:

5. PREPARED BY:

RANK / LAST NAME/ DUTY POSITION SIGNATURE

6. HAZARD: 7. INITIAL 8. 9. RESIDUAL 10. HOW TO IMPLEMENT: 11. HOW TO SUPERVISE: 12. CONTROLS
RISK LEVEL: RISK LEVEL: EFFECTIVENESS:
LIST YOUR POSSIBLE RAC CODE WHAT ARE YOUR CONTROL RAC CODE AFTER ANSWER THE ABOVE LIST YOUR SUPERVISORY AAR COMMENTS
HAZARDS HERE FEATURES FOR THE LISTED CONTROLS QUESTION TOOLS HERE
HAZARD TO THE LEFT

13. OVERALL RISK LEVEL AFTER CONTROLS ARE IMPLEMENTED: (Check One) 14. RISK DECISION AUTHORITY:
RAC 1 (CRITICAL) RAC 2 (SERIOUS) RAC 3 (MODERATE)
RAC 4 (MINOR) RAC 5 (NEGLIGBLE) RANK / LAST NAME/ DUTY POSITION SIGNATURE

MCB Form 5100/12 (12/04) (EF) PREVIOUS EDITIONS ARE OBSOLETE Designed using Adobe Form Designer 5.0
MCB/ADJ December 2004