HAZARDOUS SUBSTANCES

RISK ASSESSMENT FORM

NAME OF PREMISES	DATE ASSESSED
ADDRESS OF PREMISES	NEXT ASSESSMENT DUE

GENERAL INFORMATION

NAME OF HAZARDOUS SUBSTANCE
PURPOSE OF SUBSTANCE
LOCATION USED
AMOUNT USED, AND HOW OFTEN
FREQUENCY AND DURATION OF USE
WHO USES THE SUBSTANCE
ADDITIONAL RELEVANT INFORMATION

DESCRIPTION OF POSSIBLE HAZARDS check all that apply

Irritant	Allergic-type respiratory reaction
Acidic/Corrosive	Mutagen
Poisonous	Birth Defects
Allergic-type skin reaction
Other:
Other:

ADEQUATE CONTROL MEASURES IN PLACE check all that apply

ADEQUATE EXISTING CONTROL MEASURE	NOTES
Health monitoring program
Air quality monitoring program
Local extraction ventilation
General ventilation
Continuous training (e.g. safe handling, PPE, hazards, first aid)
First aid supplies and equipment
Personal Protective Equipment (PPE)
Emergency plan
Hazardous signage and labeling
Other:
Other:
Other:

RECOMMENDED ACTION PLAN

RISK	PERSON(S) AT RISK	RISK LEVEL (H,M,L)	PROBABILITY (H,M,L)	ACTION	OWNER

ADDITIONAL INFORMATION

ASSESSMENT CONDUCTED BY	SIGNATURE	DATE	ASSESSMENT APPROVED BY	SIGNATURE	DATE

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