HAZARD ASSESSMENT FORM
ITT Dublin RE_5 Form
The purpose of a risk assessment is to identify possible causes of harm and measures needed to
avoid these before an accident occurs.
A hazard is anything with the potential to cause harm. The risk is the likelihood that someone will
be harmed by the hazard and the severity of the harm caused. A high risk is one which is very
likely to occur and/or may cause death or serious injury/illness. A low risk is extremely unlikely
and/or would result in trivial or no injury/illness. A medium risk is in between these two. By
carrying out a risk assessment, you can direct attention and resources where they are most
needed to prevent injuries or ill health.
TO BE COMPLETED WHERE IT IS PROPOSED THAT BIOLOGICAL OR CHEMICAL
AGENTS ARE TO BE ADMINISTERED TO A ‘PARTICIPANT’ INVOLVED IN THE RESEARCH
PROJECT TITLE
Name of Chemical or Biological
Agent
Researcher’s Name(s): (use
block capitals)
School/Department/Centre:
Location of Work
STAGE 1: Hazard Identification
Does the substance pose a health hazard?
Answer YES or NO as appropriate
If so, please enter the hazard category and appropriate risk phrase below?
Low Hazard
Medium Hazard
High Hazard
Special Category
(Carcinogenic,
mutagenic, toxic
reproduction etc.)
to
LIST THE POTENTIAL HAZARDS TO HUMANS AND THE ENVIRONMENT
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STAGE 2: Hazard Evaluation
(See guidelines at the end of this form, page 3)
Risk Assessment
Frequency
Risk Number
Control
Strategy
(Avoid,
reduce
etc.)
Control
Consequence
Assessment completed by: Print Name:
Signature:
Date:
Approved by Head of Dept./School Print Name:
Signature:
Date:
STAGE 3: Safety Information
a. Properties
Enter any known chemical and physical property data. Where an entry is not applicable, then
enter N/A
pH =
Auto ignition temp. =
b.p./b.p. range =
Oxidizing properties:
m.p./m.p. range
Reducing properties:
Flash point
Explosive properties/limits:
Decomposition temp.:
Solubility:
b. Stability & Reactivity
Enter any known stability and reactivity data. Where an entry is not applicable, then enter N/A
Is the compound stable or not?
Materials to avoid:
Incompatibilities:
Hazardous decomposition products:
Does hazardous polymerization occur?
In accordance with the ITT Dublin Code of Good Research Practice, I declare that
the information provided in this form is true to the best of my knowledge and
judgement.
Signature of applicant 1:
Date:
Signature of applicant 2:
Date:
Signature of applicant 3:
Date:
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Guidelines for completing STAGE 2:
5 x 5 Risk Assessment Method
Frequency Number
1
2
3
4
5
Consequence Number
1
2
3
4
5
Descriptor
Unlikely, little chance
Not expected but could occur
Likely – even chance
Probable
Certain
Descriptor
Cut, scratch, bruise
Temporary short minor illness,
fracture of minor bone
Permanent minor illness,
fracture of major bone
Loss of limb or eye, temporary
serious illness
Loss of two limbs or eyes,
permanent serious illness or
fatality
RISK NUMBER = FREQUENCY x CONSEQUENCE
RISK NUMBER = 1 => Negligible Risk
RISK NUMBER = 25 => Disaster
RISK NUMBER > 16 => Control must be put in place
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