WORK/PROJECT TITLE:
Clearly identify the project, task, or work activity.
LOCATION(S):
Identify the building(s) and room(s) where the work will be undertaken.
DESCRIPTION OF WORK:
Brief details of what is involved in the work e.g. objectives, working method, of materials/substances used.
PERSONS INVOLVED:
Name individuals working on small projects or with serious hazards and staff groups for larger projects. Consider others who may be affected by the work e.g. maintenance staff, visitors or members of the public.
HAZARD IDENTIFICATION (state the hazards involved in the work)
List anything involved in the work that has the potential to cause harm.
RISK ASSESSMENT (make an assessment of the risks involved in the work and where possible state high, medium or low risk)
Describe the risks that are involved with the work i.e. the harm that could result from working with the hazards.
CONTROL MEASURES (state the control measures that are in place to protect staff and others from the above risks. Put in place adequate control measures for any risks that have been identified as uncontrolled.)
Describe the control measures used to minimise the risks, how they will operate and who they apply to.
DECLARATION
I the undersigned have assessed the work, titled above, and declare that there is no significant risk
/ the risks will be controlled by the methods stated on this form (delete as applicable) and that the work will be carried out in accordance with Departmental codes of practice.
Name……………………………………………………………………….. be signed and dated by him/her.
Signed …………………………………………………………… Date ……………………….
Safety Services
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