Scribd
Upload
38 views

Workplace Hazard Assessment Form

This document provides a form for assessing workplace hazards. It includes six categories to evaluate: [1] work area or workflow, [2] hazard category, [3] identified hazards, [4] assessment of severity, frequency, and probability of hazards, [5] required training, and [6] controls in place. Users are directed to another document for instructions on how to use the form to determine the significance of hazards. A legend defines ratings for the assessment categories.

Uploaded by

André Bensberg
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
38 views

Workplace Hazard Assessment Form

This document provides a form for assessing workplace hazards. It includes six categories to evaluate: [1] work area or workflow, [2] hazard category, [3] identified hazards, [4] assessment of severity, frequency, and probability of hazards, [5] required training, and [6] controls in place. Users are directed to another document for instructions on how to use the form to determine the significance of hazards. A legend defines ratings for the assessment categories.

Uploaded by

André Bensberg
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Workplace Hazard Assessment Form

Note #1: For a complete explanation on how to use this Form, please refer to our Determining Significant Hazards at Work document.
Note #2: In order to help calculate the level of significance of workplace hazards, use the legend on the next page to fill in this form.

1. Work Area/ 2. Hazard 3. Identified Hazards 4. Assessment 5. Training 6. Controls in


Work Flow Category Required Place

Physical/

A. Severity

B. Frequency

C. Probability

D. Significance
Chemical/

(0-6)

(-1-+1)
(1-3)
Biological/

(0-10)
Adequate
Ergonomic/ Y/N Y/N
Y/N
Environmental/
Safety/
Other

Location: Completed by: Date:

Workplace Hazard Assessment Form


© Industrial Accident Prevention Association, 2006. All rights reserved.
Workplace Hazard Assessment Form

A. Severity (0-6) B. Frequency (1-3)

0: No injury or illness; or quality, production, or other loss of less than $100


Number of persons who
2: Minor injury or illness without lost time; non-disruptive property damage or a may be exposed to or Number of times persons may be exposed
quality, production, or loss of $100 to $1,000 have contact with the to or have contact with the hazard
hazard
4: A lost-time injury or illness without permanent disability; or disruptive
property damage; or quality, production, or other loss of more than $1,000
but not exceeding $5,000
Less than Few times Many times
6: Permanent disability or loss of life or body part; and/or extensive loss of daily per day per day
structure, equipment, or material; quality, production, or other losses
exceeding $5,000 Few 1 1 2

Moderate 1 2 3
Note: Make dollar figures relative to your own company. Define a major
loss. How much money does that involve?
Many 2 3 3

C. Probability (-1 to +1) D. Significance (0-10)

- 1: Less than average chance of loss 0-2: Low

0: Average chance of loss 3-5: Medium

+1: Greater than average chance of loss 6-10: High

Revised February 2006

Workplace Hazard Assessment Form


© Industrial Accident Prevention Association, 2006. All rights reserved. • 1-800-406-IAPA (4272) • www.iapa.ca

You might also like