Assessment/Review Date

S/N Location/ Dept Activity Scenario/Condition Hazard*

C/ C ** Severity Likelihood Risk Level

Note

0 4 8

For each Hazard identified, need to determine the risk level and action plan is required for risk level 8 and above or below But the severity is 4. * Please refer Hazard Prompt list, can have more than one hazard for each activity. ** Please refer following list. One hazard can have more than one control. - No control 1 - Eliminate 2 - Substitute 3 - Reduce - Engineering controls 5 - Procedures/Work 6 - Skill 7 - Special Rules/Permit Instructions Training - Industrial Hygiene 9 - Administrative 10 - PPE Review