Workplace Risk Assessment Form
Workplace Risk Assessment Form
Please complete all selections of this form.
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General Information: |
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Assessment Date: |
[Date] |
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Assessment Conducted by: |
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Department Assessed: |
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Hazard Identification
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Hazard Description |
Location |
Potential Harm |
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[Loose floor tiles] |
Near Conveyor Belt |
Tripping and falling injuries |
Risk Evaluation
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Hazard |
Likelihood of Occurrence |
Severity of Harm |
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Loose floor tiles |
Likely |
Moderate |
Control Measures
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Hazard |
Required Controls |
Completion Date |
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Loose floor tiles |
Immediate repair |
[Date] |
Assessor's Signature:
[Your Name]
[Job Title]
[Date]
