Environmental Hazard Report Form Page 2
ADVERTISEMENT
1
2OFFICE USE: Safety Inspection Checklist
1. Risk Assessment Matrix
Likelihood
Major (eg.
Serious (e.g.
Insignificant (e.g.
Hazard Identified:
Minor (e.g. first
Risk Control
death/
serious injury/lost
incident but no
aid injury)
disability)
time)
injury)
_____________
Very likely (will
Immediate action required; notify
almost certainly
1
Extreme (1)
High (2)
High (2)
Medium (3)
the office. The activity must be
_____________
happen in the near
ceased immediately.
future - days)
_____________
Likely (will probably
Notify the office and implement
happen at some time
High (2)
High (2)
Medium (3)
Medium (3)
2
immediate action to minimise injury
– weeks/months)
_____________
Unlikely (could
Remedial action within one month
_____________
happen at sometime
3
High (2)
Medium (3)
Medium (3)
Low (4)
(if possible), supervisor attention
– six months to a
required.
year)
_____________
Very Unlikely (might
happen only rarely –
Medium (3)
Medium (3)
Low (4)
Low (4)
4
Monitoring only required. Beware!
five years plus)
2. Hierarchy of Control Measures
1.
Eliminate the Hazard
2. Substitute the Hazard
3. Isolate the Hazard
4. Engineering Controls
5. Administrative Controls
6. Personal Protective Equipment
Risk
Control Measure
By
Further Action Required
By Whom
Residual
Target
Date
Sign
Rating
Whom
Risk Rating
Completion
Completed
Date
I:\PQA - Community\Forms and Letters\Work, Health and Safety v2 July 15
page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form M-20a - Monthly Return Of Liquid Fuel Tax (state And County) And Environmental Response Tax Form - State Of Hawaii - Department Of Taxation
Financial
Related Categories
Parent category: Business