Hierarchy of Controls Risk Assessment Form
Use this form to identify a workplace hazard, assess exposure and current risk, and record controls using the hierarchy of controls.
Hazard Identification
Hazard Title / Name
*
Work Area / Location
*
Process / Task / Activity
*
Detailed Hazard Description
*
Exposure and Risk Assessment
Who may be exposed?
*
How often does exposure occur?
*
Rarely
Occasionally
Frequently
Continuously
Current risk level
*
Low
Medium
High
Controls and Follow-up
Hierarchy of Controls Assessment
*
Rows
Elimination
Substitution
Engineering Controls
Administrative Controls
PPE
Implemented
1
2
3
4
5
Partially Implemented
6
7
8
9
10
Not Implemented
11
12
13
14
15
Not Applicable
16
17
18
19
20
Recommended Next Action / Additional Controls
Responsible Person or Team for Follow-up
*
Submit
Should be Empty: