Risk Assessment control form

Workplace: Site Supervisor/ manager:

Name of person completing Date:
risk assessment
Description of activity:

Hazard identification and initial risk rating Control measures and actions
Likelihood of Further
Potential Consequence Risk level Current control measures
Hazard harm action/controls Responsible Date
Harm level rating & effectiveness
occurring required

Individual Support
HLTWHS002 AT4A Risk Assessment control (0521)
 Hazard identification and initial risk rating Control measures and actions
Likelihood of Further
Potential Consequence Risk level Current control measures
Hazard harm action/controls Responsible Date
Harm level rating & effectiveness
occurring required

Individual Support
HLTWHS002 AT4A Risk Assessment control (0521)
 Hazard identification and initial risk rating Control measures and actions
Likelihood of Further
Potential Consequence Risk level Current control measures
Hazard harm action/controls Responsible Date
Harm level rating & effectiveness
occurring required

Individual Support
HLTWHS002 AT4A Risk Assessment control (0521)
 Hazard identification and initial risk rating Control measures and actions
Likelihood of Further
Potential Consequence Risk level Current control measures
Hazard harm action/controls Responsible Date
Harm level rating & effectiveness
occurring required

Individual Support
HLTWHS002 AT4A Risk Assessment control (0521)
Risk Rating Matrix

Likelihood
Rare Unlikely Possible Likely Almost certain
The event will only The event is not likely The event may occur The event is likely to The event is almost
occur in exceptional to occur in a year within a year occur within a year certain to occur
circumstances within a year
Severe/Catastrophic
(Accidental death/ Medium High High Very high Very high
serious injury)
Consequence

Major
Medium Medium High High Very high
(serious injury)
Moderate
(Lost time due to Low Medium High High Very high
workplace injury)
Minor
(Minor workplace
Low Low Medium Medium High
injury –
no lost time)
Minimal
Low Low Medium Medium Medium
(no injury)

RISK LEVELS
Resolution at each level involves reducing the risk level to a lower level of risk
 Extreme – requires immediate assessment with management consideration. A detailed plan, regular monitoring and reporting is required with a target
resolution within 1 month timeframe
 High – requires immediate assessment with senior staff consideration, planning and reporting. Target resolution should ideally be within 3 months
 Medium – reviewing of existing controls and planning required. Resolution timeframe should be within 1 year
 Low – the risk may be tolerable and controlled if managed with high quality process and procedures

Individual Support
HLTWHS002 AT4A Risk Assessment control (0521)
Consequence Table

Use the following matrix to rate the consequence of each identified hazard. Where a hazard could have multiple consequences (for example, injury and financial
cost) the highest consequence should be selected.

Description
Consequence Injury Illness Environment Financial cost
Catastrophic Fatality or Fatality or Disastrous and/or Huge (greater than
permanent permanent widespread $500,000)
disability disability environmental
impact
Major Lost time injury Lost time injury Serious Major ($50,000–
(greater than 2 (greater than 2 environmental $500,000)
weeks) weeks) impact
Moderate Lost time injury (less Lost time injury (less Substantial High ($20,000–
than 2 weeks) than 2 weeks) environmental $50,000)
impact
Minor Requires basic Requires medical Small and / or Medium ($5,000–
medical treatment treatment, for localised impact $20,000)
example, for skin
rashes
Minimal Minor Minor, for example Little or no Low (less than
headache/nausea environmental $5,000)
impact

Individual Support
HLTWHS002 AT4A Risk Assessment control (0521)