OHS Concern with Risk Assessment
LOCATION
*
DATE SUBMITTED
*
/
Month
/
Day
Year
Date
NAME
not required
Team Leader Email
*
example@example.com
REFERENCE NUMBER (admin)
TYPE OF CONCERN
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Work Procedures/Duties
Transportation
Physical Work Environment
Psychological Work Environment
Equipment
MSI Related/Ergonomics
Violence
Working Alone
Work Design/Training
Other (please specify)
OTHER
DESCRIPTION OF HEALTH & SAFETY CONCERN WITH DETAILS:
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ASSESSING THE RISK:
Likelihood of Occurring;
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RARE; only in exceptional situations
UNLIKELY; not likely to occur
POSSIBLE; may occur in the foreseeable future
LIKELY; likely to occur in the foreseeable future
CERTAIN; almost certain to occur in the foreseeable future
Consequences;
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Minor Injury
Moderate Injury requiring medical attention
Serious Injury requiring specialist/hospital treatment
Critical resulting in permanent disability or death
Are you a Team Leader?
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Yes
No
STEP 1: Hazards
LIST ALL HAZARDS SPECIFIC TO THE TASK
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STEP 2: Assess The Risk
Likelihood
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Please Select
Low
Medium
High
Consequences
*
Please Select
Low
Medium
High
Risk Level
*
Please Select
Low
Medium
High
STEP 3: Control The Risk
HEIRARCHY OF CONTROL
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DESCRIBE THE CONTROL MEASURES TO BE TAKEN
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STEP 4: Complete The Assessment
RESPONSIBILITY FOR IMPLEMENTING THE CONTROLS
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TIMELINE FOR COMPLETION
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COMMENTS/QUESTIONS
Are the controls sufficient/effective in minimizing the risk?
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Are further controls required in the future?
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Is additional training required for workers?
*
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