HAZARD ANALYSIS AND RISK ASSESSMENT FORM

Take

Task Name

Position/Occupation

Company

Location

Supervisor Name and Title

Worker(s) Name and Title

Task Analysed

Frequency Rating (3-Daily/Frequently, 2-Monthly/Occasionally, 1-Quarterly/Rarely)

Severity Rating (3-Fatality/Catastrophic Property Damage, 2-Lost Time Injury/Major Property Damage, 1-Medical Aid/Minor Property Damage)

Probability Rating (3-Reasonably Probable, 2-Remote, 1-Extremely Remote)

Task Analysis

Task Steps-Activities

Photo Support

Existing or Potential Hazards

Health and/or Safety

Frequency: 

Severity: 

Probability: 

Priority Rating

Current Hazard Control

Hazard Control Required or Improvement Recommended

Department Involved in Implementation

Assigned to