Fillable Printable Hazard Identification and Risk Assessment Template
Fillable Printable Hazard Identification and Risk Assessment Template
Hazard Identification and Risk Assessment Template
Sample
HAZARDIDENTIFICATIONANDRISKASSESSMENT(HIRA)FORM
PART1:HAZARDIDENTIFICATION
(tobecompletedbytheFaculty/Service/DepartmentSafetyAdvisor).
1)TitleofActivity/EquipmentLocation(Building/Room)
Riverwatersampling(forsubsequentlaboratoryanalysis)
2)BriefDescriptionoftheActivity/Equipment
(underassessment).
Collectingariverwatersample;undertakingasiteinspectionaspartofresearch
project
Takingriverwatersamples
Siteinspection
Transportationandstorageofsamples
3)ReferenceMethodorProtocol(underassessment).
BaseduponEnvironmentAgencyGuidance.
4)PersonsAffected
(listallpersonsinyourarea,eitherstaffornonstaffwhomayperformtheactivityoruse
theequipment).
a)Staff:
(Names,ifpossible,JobTitlesplusnumbersifnot).
J.Bloggs,SeniorLecturer
A.N.Other,technician
b)NonStaff:(inc.students,(numbers,i.e.peryear/perpractical,etc.),visitorsand
generalpublic).
Post-graduatestudents(4pervisit)
5)PotentialSignificantHazards
(listallhazardsassociatedwiththeactivityor
equipment).
Slips,tripsandfallsonunevenorslipperysurfacesandsteps
Fallingintowatercourse
Hitbymobileplantandvehicles
Contactwithbacteria,pathogens,vermin
Exposuretodangerouschemicals
Confrontationwithaggressivepersons
Exposuretoneedlesandsharpobjects
Injuryfromlifting
Asphyxiationinconfinedspaces
Hitortrappedbymovingmachinery
Signed:
.........................................................
(SafetyAdvisor/RiskAssessor)
Date:..............................................................
Sample
PART2:RISKASSESSMENT
(tobecompletedbyappropriateperson)
Risk=likelihood(ofeventoccurring)xhazard(severity)
UsingthedefinitionofRiskwhichcoversbothlikelihood(chance)of
occurrenceandseverityofharm(takingintoaccountpopulationatriskand
levelofinjurypossible)calculatetheriskbygradingthelikelihood(1-4)and
theseverity(1-4),(1=Low,4=High),givingafinalfigurebetween1and16.
HazardIdentified
(seelistinPart1,Section5)
Likelihoodof
occurrence
(grade1-4)
(A)
Hazard
(Severity)
(grade1-4)
(B)
Risk
(likelihoodx
Hazard)
(AxB)
Slips,tripsandfallson
unevenorslippery
surfacesandsteps
Fallingintowatercourse
Hitbymobileplantand
vehicles
Contactwithbacteria,
pathogens,vermin
Exposuretodangerous
chemicals
Confrontationwith
aggressivepersons
Exposuretoneedlesand
sharpobjects
Injuryfromlifting
Asphyxiationinconfined
spaces
Hitortrappedbymoving
machinery
2
2
1
3
2
1
1
2
1
1
2
3
3
3
3
2
3
2
3
3
4
6
3
9
6
2
3
4
3
3
Signed:.........................................................................
Dean/Headof
School/Service/Supervisor
Date:..............................................
Sample
PART3.CONTROLMEASURES
a)EXISTING(listallcontrolsthatareexistinginplace)
Slips,tripsandfallsonunevenorslipperysurfaces
andsteps
Wearsafetyfootwear.Donotclimb
steepsurfaceswhilstcarrying
equipment.Beawareofriskof
surveyingclosetowatercourses.
Hitbymobileplantandvehicles
Wearhighvisibilityclothing.Keepto
markedfootpathswherepossible.If
asurveylocationisclosetoaroad,
extracaremustbetaken.
Adverseweatherconditions
Wearappropriateclothing.Ensure
thatsurveysareonlyconductedin
favourableweatherconditions.
Ensureprovisionofwaterproof
clothingifrequired.
Confrontationwithaggressivepersons/animals
Avoidconfrontationalsituationsand
adoptanon-confrontationmanner.
Whereverpossible,andparticularly
incertainareas,ensurethatsurveys
arecarriedoutinpairs.
Gettinglostinanunfamiliararea
Makeapreliminarysitevisitwitha
personwhoknowstheareaorwitha
map.
Generalcontrolmeasures
Observewrittenandoralguidance
providedbystaff.Informa
nominated,reliablepersonwhere
andwhensurveyistakingplaceand
overwhattimeperiod.Carry
identificationandamobiletelephone
(orhavereadyaccesstoapublic
telephone).
ExistingControlsSatisfactory?YES
(ifNOpartsb)andc)mustbecompleted)
b)SHORTTERMREQUIREMENTS
(implementationwithinsixmonths)
IMPLEMENTATION
DATE
COMPLETION
DATE
Ensureallpersonsinvolvedreadriskassessment.
Beforevisitingsite
Ensureallpersonsinvolvedhavereceivedsome
guidanceonsurveying.
Beforevisitingsite
Checkallpersonsinvolvedinsurveyhave
appropriateclothingandpersonalprotective
equipment(PPE).
Beforevisitingsite
andatsite
c)LONGTERMREQUIREMENTS
(implementationwithinsixtoeighteenmonths)
IMPLEMENTATION
DATE
COMPLETION
DATE
SignedasCompleted:............................................................Dean/HOS/HODDate:...............................
Comments:OriginaltobekeptbyFaculty/Department/Service
Assessmentreviewdate:Annual
Sample
PART4.NOTIFICATIONOFCHANGES
(TobecompletedbyLineManagerandRiskAssessor)
Anysignificantchangetotheworkingactivityorequipmentmustbesuitably
assessed.
1)DescriptionofChangestoActivity/Equipment
(Briefdetailsonly)
Noneatpresent
2)NewPotentialHazardsAssociatedwithChangedActivity/Equipment
N/A
3)ControlMeasurestobeImplemented
Nonewmeasuresrequired
Signed:.............................................................................
Dean/HOS/HOD
Date:............................
