Ref:

RISK ASSESSMENT FORM

Project: Unit:
Type of Task:
Site Location:
Contractor Name:
Subcontractors:

RISK RATING MATRIX.

Determine the level of risks using the matrix.
SEVERITY Likelyhood of an occurrence.
of
Severity Certain Very Likely Likely Unlikely Very unlikely
an occurrence be
Catastrophic: Multiple Fatalities/ Environmental release with
J 5 5 5 3 3
detrimental effects requiring external emergency services.
Major: Major illness or injury, disability/ Environmental release with
I 5 5 5 3 1
minimal off site impact.
Moderate: Serious but non-permanent injury or ill health. Onsite
H 5 5 3 3 1
release requiring environmental emergency plan to be activated.
Minor: Medical attention needed. No work restrictions/ Local on-site
G 3 3 3 1 1
environmental release treated locally.
Negligible: Minor cuts and bruises or sickness/ Nuisance release with
F 3 1 1 1 1
no adverse effect.
Likely hood E D C B A

1 =Low Risk (No further action required. Hierarchy of Controls:

Risk Rating: *Can the hazard be ELIMINATED OR REMOVED from the work place?
Likelyhood *Can the product or process be SUBSTITUTE for a less hazardous alternative?
3 =Medium Risk (Procedure to be available)
X *Can the hazard be ENGINEERED away with guards or barriers?
Severity *Can Administrative CONTROLS be adopted i.e. procedure, job rotation etc.
5 =High Risk (Full time supervision present) *Can PERSONAL PROTECTIVE EQUIPMENT & Clothing be worn to safeguard against hazard?
Ref:
RISK ASSESSMENT FORM

PERSONS AT RISK

Own employees: Sub-Contractors: Other workers: Visitors: Public:

Young Employees: Pregnant Women: Lone Workers: Disabled: Other:

Your estimation of the total number of people affected_______________________________________________________

HAZARDS- There is potential harm either through injury or ill-health.

Falls From Height: Falling Object: Lifting Operation: Dust: Demolition:

Mobile Plant: Mobile Vehicles: Excavations: Confined Space: Buried Services:

Overhead Services: Manual Handling: Vibration: Noise: Fire Explosion:

Fumes or Gas: Near or in Water: Collapse: Adverse weather: Chemical:

Other Hazards: Describe:_____________________________________________________________________________________________

Assessor’s Name Issued By Approved By

Contact No: Contact No: Contact No:
Position Position Position
Signature Signature Signature
Assessment Date Review Period Date of next review.

Reviewed By: Position: Signature:

Ref:
RISK ASSESSMENT FORM

INITIAL RATING Person Residual Risk Rating

Sl
1 Responsible
No Task Step HAZARD 3 5 CONTROL MEASURES 1 3 5
(LOW for Control
. (MEDIUM) (HIGH) (LOW) (MEDIUM) (HIGH)
) Measures
Ref:
RISK ASSESSMENT FORM