Pre-Work Risk Assessment
Complete this form to identify and mitigate potential hazards before starting work.
Job/Task Title
*
Location of Work
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person(s) Completing Assessment
*
First Name
Last Name
Describe the Work to be Performed
*
Hazard Identification and Risk Assessment
*
Rows
Hazard Description
Potential Impact
Likelihood (1-5)
Severity (1-5)
Risk Rating (Likelihood x Severity)
Hazard 1
Hazard 2
Hazard 3
Control Measures Checklist
*
Personal Protective Equipment (PPE) required
Emergency procedures in place
Hazard signage displayed
Equipment inspected and safe to use
Other (please specify)
Residual Risk After Controls
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Additional Comments or Precautions
Has the risk assessment been communicated to all workers involved?
*
Yes
No
Responsible Person's Signature
*
Submit Assessment
Submit Assessment
Should be Empty: