RISK ASSESSMENT FORM
FORM REF NO:CYC/HS/F3 JUNE 15
RISK ASSESSMENT FORM
RISK ASSESSMENT DETAILS
RISK RATING MATRIX & EVALUATION
POTENTIAL HARM
DIRECTORATE
Catastrophic
TEAM
Major
Fatal injury
RIDDOR reportable Specified Injuries/
Diseases/Dangerous Occurrence
Serious injury likely to result in a
RIDDOR reportable over 7 day injury
TITLE OF RISK
ASSESSMENT
Moderate
DETAILS OF ACTIVITY:
Minor
Multiple minor injury
Insignificant
Individual minor injuries
POTENTIAL HARM
Catastrophic
Major
Moderate
Minor
Insignificant
RISK ASSESSMENT LOG REF
OTHER RISK ASSESSMENTS
CROSS REFERENCED*
WORKPLACE INSTRUCTION
REFERENCE
17
12
6
2
1
22
18
13
8
3
23
19
14
9
4
24
20
15
10
5
Remote
Unlikely
Possible
Probable
DATE OF ASSESSMENT
More likely
to occur
Less likely
to occur
25
21
16
11
7
Highly
Probable
LIKELIHOOD
MANAGER CARRYING OUT
RISK ASSESSMENT
RISK RATING
NAME OF EMPLOYEE
CONSULTED
COLOUR
LOCATION OF ACTIVITY
*eg Manual Handling etc
SIGNATURE OF ‘MANAGER/SERVICE MANAGER’
(This is to confirm that actions have been identified to eliminate critical risks and
control high risks so far as is reasonably practicable)
Signature
LIKELIHOOD
Highly
The event is extremely
Probable
Foreseeable
The event is very
Probable
Foreseeable
The event is
Possible
Foreseeable
The event is not very
Unlikely
Foreseeable
The event is
Remote
Unforeseeable
Date
REQUIRED ACTION
SCORE
ASSESSMENT
1–5
Very Low
No action required
6 – 10
Low
No action required
11 – 15
Medium
Review/add controls
16 – 19
High
Review/add controls
20 – 22
Urgent
Review/add controls *
23 – 25
CRITICAL
WORK MUST STOP *
* Seek advice from the H&S Team
PAGE 1 OF 5
RISK ASSESSMENT FORM
FORM REF NO:CYC/HS/F3 JUNE 15
Copy this page if more space is required
HAZARD AND
RELATED
ACTIVITIES
eg Slip – wet floors;
Electric shock – use
of portable
equipment
PERSONS
AT RISK
eg employees,
pupils,
customers,
contractors,
members of
public, other
EXISTING CONTROLS
eg, Workplace Instructions,
Training, Authorised Users,
Competent Persons, Personal
Protective Equipment (PPE),
Guards
GIVE FULL DETAILS
POSSIBLE OUTCOME
Potential
Harm
(eg Minor)
Likelihood
(eg
Remote)
PAGE 2 OF 5
RESIDUAL RISK
RATING
AFTER
EXISTING
CONTROLS
(if 20 or more and no
further controls
practicable add to the
H&S Risk Register)
ADDITIONAL CONTROLS
REQUIRED?
RESIDUAL
RISK RATING
AFTER
ADDITIONAL
CONTROLS
(if 20 or more add
to the H&S Risk
Register; if 23+
STOP ACTIVITY)
RISK ASSESSMENT FORM
FORM REF NO:CYC/HS/F3 JUNE 15
ACTION PLAN (insert additional rows if required)
Further control measures identified to reduce risks
so far as is reasonably practicable
TO BE ACTIONED BY
POSITION
NAME
ACTION COMPLETE
DATE
SIGNATURE
1
2
3
4
Confirm risk assessment findings and controls have been
communicated to staff (and others who need to know)?
Record the process for this in the comments box below
COMMENTS AND INFORMATION
(Use this section to record how the risk assessment has been communicated and any other comments and information)
PAGE 3 OF 5
DATE
RISK ASSESSMENT FORM
FORM REF NO:CYC/HS/F3 JUNE 15
SCHEDULED DATE
OF NEXT REVIEW
(MINIMUM
ANNUALLY; IF
THERE ARE ANY
SIGNIFICANT
CHANGES;
FOLLOWING AN
INCIDENT OR
NEAR MISS)
ARE THERE ANY CHANGES TO THE ACTIVITY SINCE THE LAST ASSESSMENT?
CLARIFY THAT ALL CONTROLS ARE STILL IN PLACE & MONITORED ON A REGULAR BASIS.
PAGE 4 OF 5
SIGNATURE OF
MANAGER
DATE OF
REVIEW
RISK ASSESSMENT FORM
FORM REF NO:CYC/HS/F3 JUNE 15
OBSERVATIONAL MONITORING
Look at the activity taking place – are all the controls identified in the risk assessment & workplace instruction in place and being
followed appropriately? Also consider equipment, PPE, training, contractors etc.
ACTION(S) REQUIRED
DATE TO COMPLETE
Name & signature of manager carrying out monitoring:
Date:
Name & signature of employee(s) being monitored:
Date:
Name & signature of manager carrying out monitoring:
Date:
Name & signature of employee(s) being monitored:
Date:
PAGE 5 OF 5
DATE
ACTIONED