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HSE COSHH Assessment Form Template

This COSHH assessment template was based on the Health and Safety Executive (HSE) and was converted using Lumiform. Start by listing chemical hazards and substances present in the workplace.

Provide details of their usage and the people who may be exposed. Next record information on how the substance could cause harm and how much of the substance will be used for the job. Record Workplace Exposure Limits (WELs) and emergency procedures set by the management.

Next, complete the information about the methods of prevention or control of exposure. Lastly, provide an overall rating of the assessment and affix a digital signature to validate the audit.

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Hazard Identification
Click + to add hazards identified Note: *If the substance has a R45 or R49 risk phrase or a H350 or H350i hazard statement, it must also be registered on your personal carcinogen return (at Occupational Health) where exposure is not adequately controlled.
Name of Chemical
What will the chemical be used for?
Who may be exposed?
Hazardous Properties (Provide details of how the substance could cause harm, e.g. harmful by inhalation, skin contact, flammable, carcinogen, allergen, etc)
Quantity (Indicate how much of the substance will be used)
Workplace Exposure Limits (WELs)
Emergency procedures
What are the emergency procedures needed?
Methods of Prevention or Control of Exposure
Engineering controls required
other engineering control needed
Access control
other access control needed
Special procedures
other special procedure needed
Approved PPE
Other approved PPE used
Disposal Procedures Note: (Give details of waste disposal procedure to be used)
Are chemicals with risk phrases R50-R59 or hazard statements H400 – H413 (environmental hazards) involved?
Training Requirements Note: (List any specialised training requirements before work can begin)
Handling and Storage Requirements (Note any special requirements e.g. ventilation, chemical incompatibility, flash point, etc)
Assessment of Risk Using Controls Detailed Above
Are the hazards/risks suitably controlled, using the control measures detailed above?
state the further actions required, e.g. Requirement for a standard operating procedure (SOP), etc
Authorization by Employer/Supervisor
I confirm that I have considered and understand the chemical to be used and the associated hazards. I am satisfied that all of the hazards have been identified and that the control measures to be followed will reduce the risks to as low a level as reasonably practicable.
Full Name and Signature of Inspector
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Please note that this checklist template is a hypothetical appuses-hero 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.
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