Hazard Analysis and Risk Assessment Form

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Hazard Analysis and Risk Assessment Form

Task

Position/Occupation

Company

Location

Supervisor Name and Title

Worker(s) Name and Title

Frequency Rating (3-Daily/Frequently, 2-Monthly/Occasionally, 1-Quarterly/Rarely)Severity Rating (3-Fatality/Catastrophic Property Damage, 2-Lost Time Injury/Major Property Damage, 1-Medical Aid/Minor Property Damage)Probability Rating (3-Reasonably Probable, 2-Remote, 1-Extremely Remote)

Task Analysed

Task Analysis

Task Steps-Activities

Photo Support

Add Photo

Existing or Potential Hazards

Health and/or Safety

Select Health Safety

Frequency

1 2 3

Severity

1 2 3

Probability

1 2 3

Priority Rating

Current Hazard Control

Hazard Control Required or Improvement Recommended

Department Involved in Implementation

Engineering Administration PPE

Assigned to

Please note that this checklist template is a hypothetical example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.