SAMPLE RISK ASSESSMENT FORM: Guide to Risk Assessments and Safety Statements

https://www.hsa.ie/eng/Publications_and_Forms/Publications/Safety_and_Health_Management/Guide_to_Risk_Assessments_and_Safety_Statements.pdf Retrieved on November 19, 2020

SAMPLE RISK ASSESSMENT – SLIPS, TRIPS AND FALLS

Step 1: Step 2: Step 3:

What are the hazards? Who is/are at Current Controls Level of risk Additional Controls needed Action by whom and Date
risk? (What are you already doing?) (Your estimate of (Further action to reduce the remaining by when? Completed
the remaining risk level to as low as possible)
risk level, based
on the current
controls. For
example High,
Medium, or Low)

Slips, Trips and Everyone – 1. Clear, unobstructed, slip-resistant Medium 1. Changes in levels are avoided if John Smith by
Falls employees pedestrian routes (Including possible or adequately August 2018
Can cause serious and entrances and exits) are provided highlighted where necessary –
injuries For example visitors and maintained steps outside the side entrance
fractures, head 2. Adequate lighting is provided and is are dark and hard to see
injuries appropriate for the work being 2. Trailing cables and leads are John Smith by 30th
carried out rerouted, removed or secured – June 2018
3. Absorbent materials and warning not done in the main office
signage are available for dealing
with spills
4. Spills are cleaned up immediately
5. Mats are properly located, fitted
and secured
6. Good house-keeping practices are
in place and are maintained
7. Slip resistant footwear is provided
and worn by kitchen staff

Risk Assessment Completed By: ____Joe Bloggs________________ Date: ___28th June 2018__________
SAMPLE RISK ASSESSMENT – CHEMICALS

Step 1: Step 2: Step 3:

What are the hazards? Who is/are at Current Controls Level of risk Additional Controls needed Action by whom and Date
risk? (What are you already doing?) (Your estimate of (Further action to reduce the remaining by when? Completed
the remaining risk level to as low as possible)
risk level, based
on the current
controls. For
example High,
Medium, or Low)

Chemicals - Employees, 1. Chemical labels and Safety Data Medium 1. A list (inventory) of all John Smith by
can cause fires, visitors Sheet are available for each chemicals used in the July 2018
explosions, skin chemical and the associated workplace has been prepared
and eye irritation, hazards of each chemical has been 2. Less hazardous chemicals are John Smith by
cancer, ill health identified used where possible – look in November 2018
and other serious 2. The number of employees and the to alternatives we can use
injuries exposure to chemicals is assessed
and minimized
3. Employees are trained in the safe
use of chemicals
4. Adequate ventilation is provided
5. A wash hand basin, soap and
disposable towels / hand dryer are
available
6. All chemicals are used, stored and
disposed of in accordance with the
Safety Data Sheet or supplier
recommendations
7. Eye, skin and respiratory protection
is
8. provided and worn where
appropriate and in accordance with
the safety data sheet

Risk Assessment Completed By: ____Joe Bloggs________________ Date: ___28th June 2018__________