Company Name: ______________________
Location/Department: ______________________
Date of Assessment: ______________________
Conducted By: ______________________
Reviewed By: ______________________

1. Scope of Assessment:

• Purpose: Briefly describe the reason for the assessment (e.g., routine safety review, new equipment, workplace change).

• Areas Covered: Specify areas or processes covered in the assessment.

2. Identify Hazards:

3. Risk Evaluation:

For each hazard identified, assess the likelihood of an incident and the severity if it occurs.

• Likelihood: Rare, Unlikely, Likely, Almost Certain

• Severity: Minor, Moderate, Major, Catastrophic

• Risk Rating (Likelihood x Severity):
  (Low, Medium, High, Critical)

Example:

4. Existing Controls:

List current safety controls in place for each hazard.

Example:

• Wet floors: "Signage for wet floors, slip-resistant mats."

• Chemical exposure: "Ventilation system, PPE for lab workers."

5. Additional Control Measures Required:

Identify any further safety measures or corrective actions needed to reduce risks.

Example:

• Wet floors: "Improve lighting and increase cleaning schedule."

• Chemical exposure: "Conduct regular air quality checks, provide better PPE."

6. Action Plan:

• Action Steps: Detailed steps to be taken to mitigate the risks.

• Responsible Person: Name or role of the person responsible for implementing the actions.

• Completion Date: Deadline for implementing each measure.

• Status: (Not Started, In Progress, Completed)

Example:

7. Review and Monitoring:

• Review Date: Specify when the assessment and controls will be reviewed for effectiveness.

• Monitoring Plan: Describe how ongoing monitoring will be conducted.

8. Sign-Off:

• Safety Officer/Manager Name & Signature: ______________________

• Date: ______________________

• Employee Representative (if applicable): ______________________

• Date: ______________________

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