Hazardous Substances Risk Assessment Form

Hazardous Substances Risk Assessment Form

Site: / Hazardous Substance: / Manufacturer:
Location of Substance: / Used By:
Assessment Team: / Date: / Time: / Signature/s:
Reported Health Effects:

Ingredients/Exposure Limit

/ Chemical State: / Poison Schedule / DG Class & Sub Risks /

POTENTIAL HAZARDS

Toxicity /

Flammability

/ Corrosive / Other*
Description of Use/s / Routes of Entry / Existing Controls / Exposure Frequency / Likelihood /

Consequence

/

Risk Conclusion**

/

Further Action Required

(Refer to Action Plan)
Comments:
Approved By: (NAME) / Date: / Signature:
Hazard Identification Table OTHER (*)
ASP / Asphyxiants / GEN / Genetic damage / RAD / Radioactive
BIO / Biological / HARM / Harmful / REAC / Reactivity
CARC / Carcinogenic / IRRT / Irritant / REPR / Toxic to reproduction
DEVL / Developmental toxic / IRVER / Irreversible effects / SEN / Sensitiser
DIW / Dangerous if wet / MUTA / Mutagen / SPON / Spontaneous Comb.
EXP / Explosive / OXD / Oxidizer / Comp. Gas / Compressed gas

Action Plan

Identified Hazards / Control Action Required / Priority / By Whom / By When / Completion Date
Further Follow up Required ?
YES / NO / Date of Follow up / Comments
Further Follow up Required ?
YES / NO / Date of Follow up / Comments
Further Follow up Required ?
YES / NO / Date of Follow up / Comments
Are all Actions Closed Out ? YES / NO / Date: / HSE Rep. Signature:
Entered into Hazardous Substances RegisterYES / NO / Date of Entry / Comments
Likelihood / Value / /

Exposure Factor

/ Value / Consequences / Value
a)  Might well be expected
b)  Quite possible
c)  Unusual but possible
d)  Only remotely possible
e)  Conceivable but very unlikely
f)  Practically impossible
g)  Virtually impossible / 10
6
3
1
0.5
0.2
0.1 / a)  Continuous
b)  Frequent (daily)
c)  Occasional (weekly)
d)  Unusual (monthly)
e)  Rare (a few annually)
f)  Very rare (yearly or more) / 10
6
3
2
1
0.5 / a)  Catastrophe (many fatalities or > $107 damage)
b)  Disaster (few fatalities or > $106 damage)
c)  Very Serious (fatality or > $105 damage)
d)  Serious (major injury or > $104 damage)
e)  Important (disability or > $103 damage)
f)  Noticeable (first aid injury or > $102 damage) / 100
40
15
7
3
1