Risk Assessment Form
Complete this form when assessing new tasks, reviewing risk register controls or reviewing medium to high level risks.
The person(s) undertaking the risk assessment completes Parts 1 and 2 of this Form. Parts 3 and 4 are completed by relevant others.
Part 1
Site / Location:
Work Activity Title:
Names of Person(s) Conducting Risk Assessment: (minimum 2 competent persons)
Permit to Work Number / WO Number: (if applicable)
ID #:
Date:
Inherent Risk Level
(L, M, H, E)
List the hazards relating to each task
(use the Hazard / Energy Table as a
guide)
Likelihood
(R/U/P/L/AC)
List in sequence the tasks involved in the work
activity (e.g. pre-start preparation through to
work completion)
Step 3
Inherent Risk
(Use Matrix)
Consequence
(M/SIG/SER/CR/CAT)
Hazards
Step 4
Controls
Responsible Person(s)
For each identified hazard, list the controls to
be implemented [use the Hierarchy of Controls
as a guide i.e. (1) elimination, (2) substitution,
(3) engineering/isolation, (4)
administrative/training, (5) PPE]
List the role, prescribed
occupation etc. responsible for the
controls (eg. supervisor, machine
operator, electrician, scaffolder
etc).
Residual Risk
(Use Matrix)
Likelihood
(R/U/P/L/AC)
Residual Risk Level *
(L, M, H, E)
Step 2
Tasks
Control Effectiveness
(U/P/S/G/VG)
Step 1
Task
No.
(if applicable)
Consequence
(M/SIG/SER/CR/CAT)
Work Order ID #:
Following this form are the Reference Tools you will need to complete this table.
Note *Residual Risk Level – you cannot move from an extreme inherent risk to a low residual risk, regardless of controls, without the approval of your Senior Manager or GM
Note: for five years
Document: Operational Risk  Risk Assessment Form
Page 1 of 6
Date: 13 July 2015
Controls
Responsible Person(s)
For each identified hazard, list the controls to
be implemented [use the Hierarchy of Controls
as a guide i.e. (1) elimination, (2) substitution,
(3) engineering/isolation, (4)
administrative/training, (5) PPE]
List the role, prescribed occupation
etc. responsible for the controls (eg.
supervisor, machine operator,
electrician, scaffolder etc).
Residual Risk
(Use Matrix)
Likelihood
(R/U/P/L/AC)
Residual Risk Level *
(L, M, H, E)
Inherent Risk
(Use Matrix)
Step 4
Consequence
(M/SIG/SER/CR/CAT)
List the hazards relating to each task
(use the Hazard / Energy Table as a
guide)
Step 3
Inherent Risk Level
(L, M, H, E)
Hazards
List in sequence the tasks involved in the work
activity (e.g. pre-start preparation through to
work completion)
Likelihood
(R/U/P/L/AC)
Tasks
Consequence
(M/SIG/SER/CR/CAT)
Task
No.
Step 2
Control Effectiveness
(U/P/S/G/VG)
Step 1
Following this form are the Reference Tools you will need to complete this table.
Note *Residual Risk Level – you cannot move from an extreme inherent risk to a low residual risk, regardless of controls, without the approval of your Senior Manager or GM
Note: for five years
Document: Operational Risk  Risk Assessment Form
Page 2 of 6
Date: 13 July 2015
Part 2
Method for Monitoring / Reviewing Controls:
Describe how the controls will be monitored and reviewed during the work activity (include reference to any inspections or checks and those responsible for monitoring).
Part 3 – Completed by Approving Authority (refer Actions and Authority Table below the Consequence/Likelihood Matrix and Control Effectiveness Table)
Risk Assessment Review and Approval (Supervisor or Manager):
This Risk Assessment has been reviewed and approved. All controls are to be communicated via a Tool Box Talk to relevant persons and implemented as documented.
Approving Person’s Name
Signature
Date
Time
Part 4 – Completed by Relevant Persons to whom the Work Activity applies
Risk Assessment Communication:
The detail and requirements of the above Risk Assessment have been communicated to me and I fully understand the hazards and control measures to be implemented as part of this work activity. I have reviewed the content of the
above Risk Assessment and have made suggestions/changes as required to ensure the hazards and controls correctly reflect the work that I am completing.
Name
Signature
Date
Part 5 – Follow Up for Medium, High and Extreme Residual Risks
Risk Register Update and Communication (if required when new tasks or amended/new controls identified):
I have updated the Operational Risk Register and communicated the changes to relevant persons in a Tool Box Talk.
Supervisor’s/Manager’s Name
Signature
Date
Note *Residual Risk Level – you cannot move from an extreme inherent risk to a low residual risk, regardless of controls, without the approval of your Senior Manager or GM
Completed form to be scanned and filed in CREWS:
(Health, Safety & Emergency Response / Work Activities / Work Activity Risk Assessments / [Folder for relevant year])
Note: for five years
Document: Operational Risk  Risk Assessment Form
Page 3 of 6
Date: 13 July 2015
Operational Risk Assessment Tool
Step 1: Identify Tasks & Hazards
Describe the activity, list tasks and hazards. For each task assess and score Inherent Risk, Controls and Residual Risk.
Consequences (Worst Case, Most Credible Outcome)
Step 2: Inherent Risk
(no controls)
MINOR (M)
SIGNIFICANT (SIG)
SERIOUS (SER)
CRITICAL (CR)
CATASTROPHIC (CAT)
Class C – Minor injury (first
aid)
Potential loss <$10k
Minor impact on the
environment that can be
remedied
Class B – Significant injury
(medical treatment)
Potential loss $10k to $25k
Major impact on the
environmental that can be
remedied
Class B – Long term injury
Potential loss $25k to $50k
Prohibition notice from WHS
Permanent environmental
impact to local area
Class A – permanent disabling
injury
Potential loss $50k to $150k
Critical long term impact on the
environment over a widespread
area
Class A – one or more fatalities
Potential loss >$150k Port closure
Irreversible environmental impact to
widespread areas/species
Almost Certain (AC) - Is expected to occur in
most circumstances
Medium
High
Extreme
Extreme
Extreme
Likely (L) - Will probably occur
Medium
Medium
High
Extreme
Extreme
Possible (P) - Might occur at some time in the
future
Low
Medium
High
High
Extreme
Unlikely (U) - Could occur but doubtful
Low
Medium
Medium
Medium
High
Rare (R) -May occur but only in exceptional
circumstances
Low
Low
Low
Medium
Medium
Unplanned Event)
(of the Hazard or
Likelihood
Step 4: *Residual Risk
(with controls)
Step 3: Document controls and rate effectiveness
Very Good (VG)
Comprehensive controls in place, minor opportunities to enhance control design and level of compliance
Good (G)
Controls in place but there are some gaps arising from control design and/or operational effectiveness
Satisfactory (S)
Some controls in place but there are gaps arising from control design and/or operational effectiveness
Poor (P)
Limited controls in place, controls are poorly designed and/or have limited effectiveness
Uncontrolled (U)
No credible controls, no designed controls and/or operationally ineffective controls
Effectiveness – How good are the controls? Are they
industry standard or better? Best available? Are the controls
engineered controls, procedures or PPE?
Assurance – Think about how sure you are that the controls
are used. Are they monitored/ audited? Is there a checklist
or record of use?
Actions and Authority Table
Residual Risk
Actions Required
Extreme
Do not undertake this task. Contact your supervisor, manager, General Manager or Health and Safety team. Additional controls needed.
High
Approval required by Head of Business Unit to undertake this task. Additional controls are to be implemented wherever possible.
Medium
Tasks can be undertaken immediately by implementing all the identified controls. Supervisors or managers must review and approve tasks and controls before the activity is completed
and suggest improvements if appropriate.
Low
Tasks can be undertaken immediately by implementing all the identified controls. Supervisors or managers have the discretion to review and approve tasks and controls before the
activity is completed.
Note *Residual Risk Level – you cannot move from an extreme inherent risk to a low residual risk, regardless of controls, without the approval of your Senior Manager or GM
Note: for five years
Document: Operational Risk  Risk Assessment Form
Page 4 of 6
Date: 13 July 2015
Energy Hazard Table
When you are thinking about a hazard remember that it could result in harm to people (employees, contractors
and visitors), the environment and/or property.
Energy - Hazard Types
Hazard Examples
Gravitational Energy
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Fall from height
Falling objects
Slips and trips
Access/work beneath a suspended load
Kinetic / Mechanical
Energy

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Contact with moving plant/parts (cutting, shearing, drawing in, entanglement, etc)
Contact with moving vehicles/vessels/mobile plant
Contact with sharp objects
Struck by projectiles and ejected items (including struck by foreign object in the eye)
Mechanical damage to PPE, services or other items
Contact with stationary/immovable objects
Thermal and/or
Explosive Energy
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Contact with hot/cold objects
Excessively hot/cold environments (including heat stress)
Fire/Explosion
Ignition of gas/dust in a hazardous area
Electrical Energy
 Contact with live electrical parts (overhead power line, welding electrode, induced
voltage)
 Exposure to high fault currents (within switchboards, battery banks)
 Ingress of water into electrical components
 Mechanical damage to power leads/fixed electrical wiring
 Incorrect connection of wiring
Chemicals /
Substances Energy
 Ingestion of chemicals/substances
 Inhalation of dusts, gases, fumes, vapours and mists
 Absorption of chemicals/substances through the skin
Radiation Energy
 Exposure to ionising radiation source (industrial radiography, non-destructive testing)
 Exposure to non-ionising radiation source (ultraviolet, laser, welding flash, infrared,
microwave, radiofrequency)
Noise and/or
Vibration Energy
 Exposure to increased noise (levels that may cause hearing damage/employee
discomfort)
 Contact with vibrating plant/vehicles
 Contact with vibrating tools/objects
Pressurised Energy
 Release of a stored gas, liquid, solid under pressure
 Release of spring/tension energy
 Contact with pressurised agent
Manual Handling /
Postural Hazards
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Handling heavy, unstable or awkward objects/loads
Maintaining static or awkward work postures
Repetitious movements
Tool use that requires excessive force
Inappropriate ergonomics/body movements
Document: Operational Risk  Risk Assessment Form
Page 5 of 6
Date: 13 July 2015
Energy - Hazard Types
Biological Hazards
Hazard Examples
 Exposure to algal, bacterial, fungal, viral or parasitic agents (skin contact, ingestion,
inhalation)
 Animal, insect and spider bites/stings
 Sharps injury/needle-stick exposure
Psychological, Mental, 
Social and Medical

Hazards
Exposure to workplace bullying, harassment, violence
Working for excessive time periods and/or while fatigued
 Working under the influence of alcohol/drugs or other agents
Work Environment
Hazards
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Environmental
Hazards
 Unauthorised emissions to air, land or water
 Release of a stored chemical
 Spill or leak resulting in contamination of waters (including disposal into incorrect
drains)
 Release of a harmful solid, liquid or gas during transport on/off site
 Bush Fires/Explosion
 Chemical/contaminant spills or other work activities resulting land contamination
 Incorrect waste disposal
 Uncontrolled release of contaminants (oil, coolants, other substances)
 Import of unauthorised soils, materials, plants or machinery
Working alone
Inadequate lighting
Wet/slippery floor/surface
Uneven/unstable ground or working surface
Weather conditions eg. floods, lightning, wind
Atmospheric conditions eg. dust, vapours, oxygen depletion
Restricted/confined space access or working space
Inability to communicate due to noise
Inability to swim
Failure to follow correct procedure/Permit to Work
Inappropriate/Unauthorised access to construction/work area
Contractor not performing work safely
Uncontrolled ingress of water into a vessel
Document: Operational Risk  Risk Assessment Form
Page 6 of 6
Date: 13 July 2015