Hazard Evaluation Form

Date:	[Month Day, Year]
Location/Area:	[Location/Area Name]
Evaluator:	[Your Name]

1. Hazard Identification:

Hazard Description:

                                                                                                                                                                                                                                                                                                                                                                                                                           

Type of Hazard:

• Chemical

• Physical

• Ergonomic

• Others (Please specify):                               

Potential Impact:

                                                                                                                                                                                                                                                                                                                                                                                                                           

2. Risk Assessment:

Likelihood of Occurrence

• Low

• High

• Medium

Severity of Consequence:

• Low

• High

• Medium

Risk Level

• Low Risk

• Medium Risk

• High Risk

Existing Controls:

                                                                                                                                                                                                                                                                                  

3. Recommended Actions:

Proposed Controls:

                                                                                                                                                                                                                                                                                  

Responsibility:

                                                                                                                                                                                                                                                                                  

Timeline:

                                                                                                                                                                                                                                                                                  

4. Additional Comments/Notes:

                                                                                                                                                                                                                                                                                                                                                                                                                           

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