No.

Sample Form Risk Assessment

For general risk assessment or activity where other risk assessment forms not available or suitable

Site: BHSEA c/o Birmingham Medical Institute Area / Department: Conference Room
Initiated by: Syndicate Group No. ....... Date: 11th April 2011 Agreed by: …………………………………. Date: ............................................
PART 1 BASIC INFORMATION – include / attach photo
Photo / picture:
Replace blade on mixer .......................................................................................................................................................................
Activity .................................................................................................................................................................................................................
.................................................................................................................................................................................................................

Workplace Location of activity: Coating Department...............................................................................................................................................

.................................................................................................................................................................................................................
Machine / equipment / tools involved: Mixer for coating equipment
Machine /
equipment No. 1 ........................................................................................................................................................................................................
.................................................................................................................................................................................................................

Hazardous materials Hazardous materials / substances to be used or likely to arise: ............................................................................................................

/ substances
Solvent; Fine non-toxic powder………………………………….……………………….…….. Data sheet(s) available? yes † no †.
PART 2 HAZARDS & RISKS if necessary do detailed risk assessment(s) & attach
What significant hazards / hazardous conditions exist or could arise? Who or what could be harmed? How serious do you think the risk is?
e.g. as a result of failure(s)or something going wrong? (Before actions / precautions are taken)
† Slipping / tripping hazards † Poor lighting † Operators † Lone workers † High
† Work at height † High or low temperature † Office staff † Contractors † Medium
† Noise / vibration † Confined space † Maintenance personnel † Cleaners † Low
† Moving parts of machinery / tools † Ejection of material † Inexperienced staff † Visitors Further explanation: .................................
† Stored energy incl. gravity † Operation without warning † Young persons † Public
† Lifting & transportation equipment † Pressure systems ...................................................................
† Staff with disabilities
† Electricity † Radiation † Environment (land, air, water) ...................................................................
† Vehicles e.g. fork lift trucks † Manual handling † Buildings / property ...................................................................
† Awkward / uncomfortable posture, excessive or repeated twisting,
bending or reaching involving trunk, shoulder, head, arm or wrist ...................................................................
† Hazardous chemicals/substances † Flammable materials Other / details: ..................................................
† Vapour, dust or fumes † Hazardous waste ...................................................................
...........................................................................
† Other / details: ...................................................................
...........................................................................
…………………………………………………………..........
...................................................................
...........................................................................
.........................................................................................................................
PART 3 DECIDING WHAT ACTION TO TAKE Review for each hazard, if necessary do detailed risk assessment(s) & attach
Can the hazard(s) be avoided by elimination? Most preferred
Can substitution e.g. other equipment, substance or work method, reduce the risk? Make note(s) in PART 4 below & / or
Can engineering controls eliminate or reduce the risk? include in standard work sheet,
Is a written safe system of work / procedure or a permit to work needed? written system of work / procedure,
Is personal protective equipment (PPE) needed? Least preferred
Could there be problems or could anything fail or go wrong. yes † no † If yes provide details. or permit to work - as appropriate
Is a more detailed assessment & / or expert advice needed? yes † no † If yes get help.
PART 4 NOTES / ACTIONS / IMPROVEMENT OPPORTUNITIES ETC Proposal Action taken –
- attach any additional information including photo after actions etc completed considered by / date
by / date
.................................................................................................................................................................................................................. ....................... .............................
.................................................................................................................................................................................................................. ....................... .............................
.................................................................................................................................................................................................................. ....................... .............................
.................................................................................................................................................................................................................. ....................... .............................
.................................................................................................................................................................................................................. ....................... .............................
.................................................................................................................................................................................................................. ....................... .............................
.................................................................................................................................................................................................................. ....................... .............................
.................................................................................................................................................................................................................. ....................... .............................

Risk Assessment Issue 4 Minor reformat July 2007 f1143