Fillable Printable COSHH Assessment Form
Fillable Printable COSHH Assessment Form
COSHH Assessment Form
1
COSHH Assessment Form
This assessment only addresses the risk of harm to health from the substances listed. Additional risk
assessments may be required to control the risk from other hazards associated with this work/the procedures used.
Assessor (
print
)
(1)
Employer/Supervisor
(2)
Assessment Date
(3)
Dates reviewed
(4)
HAZARDS IDENTIFIED
*If the substance has a R45 or R49 risk phrase or a H350 or H350i hazard statement, it must also be registered on
your personal carcinogen return (at Occupational Health) where exposure is not adequately controlled.
Substance
(5)
(Name of Chemical, etc. as appropriate);
NB.
Hazardous Properties
(6)
(Provide details of how the substance
could cause harm, e.g. harmful by
inhalation, skin contact, flammable,
carcinogen, allergen, etc)
Quantity
(7)
(Indicate how much of the
substance will be used)
Additional information
(8)
Workplace Exposure Limits:
R-phrases:
S-phrases:
H and P statements:
Emergency Procedures
(9)
Eye contact:
Inhalation:
Skin contact
Ingestion:
Spill procedure:
What will the chemical be used for? (insert title of experiment or experimental procedure) Who may be
exposed?
(10)
2
METHODS OF PREVENTION OR CONTROL OF EXPOSURE
(select all that apply by circling/ticking/highlighting the appropriate statement)
1. Engineering controls required
(11)
total containment
fume cupboard
local exhaust ventilation
blast screen
2. Access control
(12)
restricted to competent personnel
special containment facility (give specific area):
3. Special procedures
(13)
Standard Operating Procedure (SOP) required
Code of practice, local rules, etc
4. Approved PPE
(14)
( Note: PPE is to be used as the
‘last resort’ when controlling exposure)
gloves etc (specify type)
eye protection (specify type)
laboratory coat/overalls (specify type)
other PPE (specify)
Disposal Procedures
(15)
(Give details of waste disposal procedure to be used)
Are chemicals with risk phrases R50-R59 or hazard statements H400 – H413 (environmental
hazards) involved? Yes / No
TRAINING REQUIREMENTS
(16)
(List any specialised training requirements before work can begin)
HANDLING AND STORAGE REQUIREMENTS
(17)
(Note any special requirements e.g. ventilation, chemical incompatibility, flash point, etc)
ASSESSMENT OF RISK USING CONTROLS DETAILED ABOVE
(18)
(Are the hazards/risks suitably controlled, using the control measures detailed above? If not, state the further
actions required, e.g. Requirement for a standard operating procedure (SOP), etc).
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Authorisation by Employer/Supervisor
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I confirm that I have considered and understand the chemical to be used and the associated hazards. I am
satisfied that all of the hazards have been identified and that the control measures to be followed will
reduce the risks to as low a level as reasonably practicable.
Print name: Signed:
Date:
Declaration by Employer/Supervisor
(20)
I confirm that I have read this COSHH Assessment and that I understand the hazards and
risks involved and will follow all of the safety procedures stated.
Declaration by employee
201
I confirm that the employee who has signed below is competent to undertake the work. My
counter-signature indicates that I am happy for the work to proceed.
Name (please print)
Signed
PI countersignature
date
4
Guidance notes for COSHH assessment form
This form must be completed for every hazardous chemical used within the company. The
form must be signed by the employee and their employer/supervisor before the work starts.
(1) Assessor: Insert the name of the person doing this assessment
(2) Employer/Supervisor Insert the name of the Employer/Supervisor.
(3) Assessment Date: Insert the date that the assessment form is completed. The
assessment is valid for a maximum of 1 year. It must be reviewed after 1 year, or if a
significant change occurs (change of lab, pregnancy, etc).
(4) Dates reviewed: all COSHH assessments must be reviewed annually (as a minimum).
The review date should be entered here, and signed by the assessor to confirm that the
assessment is still valid.
(5) Substance: insert name of the chemical to be used. NB. Biological hazards must not
be assessed on this COSHH form.
(6) Hazardous properties: insert details of all of the hazardous properties of the
chemical – egg. Flammable, explosive, carcinogen, harmful by inhalation, etc).
(7) Quantity: insert quantity to be used (mg, g, ml, etc)
(8) Additional information: Include details of any additional information, including any
workplace exposure limits. Detail fully all R/S phrases and H and P statements (it is not
sufficient to simply stat R45, full details are needed).
(9) Emergency procedures: provide full details of emergency procedures to be employed
following contact with the chemical (skin contact, eye contact, inhalation and
ingestion) – such as use of diphoterine, administration of emergency oxygen, etc. Also
include details of emergency spill procedures.
(10) What will the chemical be used for? Who may be exposed? : Insert title of
experiment or experimental procedure that the chemical is to be used in, and detail
who may be exposed (individual worker? People in close proximity? Cleaners?
Engineers?).
Methods of prevention or control of exposure
Sections 11-14 detail the methods for preventing or controlling exposure to the chemical. The
COSHH hierarchy of control measures should be used when determining the methods to be
used to prevent/control exposure, with engineering and group control measures being
employed in preference to individual measures (such as individual PPE).
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(11) Engineering controls required: identify the control measures necessary to
prevent/control exposure, such as use of a fume cupboard, LEV or blast screen, by
circling/ticking/highlighting the appropriate statement(s).
(12) Access control: In order to prevent/control exposure, is it necessary to restrict access
to competent personnel? Are special containment facilities required? Please
circle/tick/highlight the appropriate statement(s).
(13) Special procedures: please identify any special procedures necessary to
prevent/control exposure. This might include the need for an SOP to be developed, or
for local rules to be drawn up. Please circle/tick/highlight the appropriate statement(s).
(14) Approved PPE: PPE is to be used as the ‘last resort’ when preventing/ controlling
exposure. Please detail the PPE to be used when handling the chemical. Please
circle/tick/highlight the appropriate statement(s) and include details of the type of
gloves, etc to be used.
(15) Disposal procedures: Identify whether the chemical is an environmental hazard;
Detail fully how the chemical waste is to be disposed of (down sink, by specialist
contractor, etc)
(16) Training requirements: detail any specialised training requirements that must be met
before the work can begin – eg. Attendance on a gas safety course, etc).
(17) Handling and storage requirements: Note any special requirements e.g. ventilation,
chemical incompatibility, flash point, etc.
(18) Assessment of risk using controls detailed above: Are the hazards/risks suitably
controlled, using the control measures detailed above? Provide details; If not controlled,
state the further actions required, eg. Requirement for a standard operating procedure
(SOP), etc.
(19) Authorisation by Employer/Supervisor: the employer/supervisor must sign and
date the assessment, to confirm that they have considered and understand the
chemical to be used and the associated hazards, and that they are satisfied that all of
the hazards have been identified and that the control measures to be followed will
reduce the risks to as low a level as reasonably practicable.
(20) Declaration by employee: the employee must sign and date the assessment to
confirm that they have read the COSHH Assessment, understand the hazards and
risks involved and will follow all of the safety procedures stated.
(21) Declaration by
Employer/Supervisor
:
the
employer/supervisor
must sign and
date the assessment, to confirm that the researcher is competent to undertake the work.
