Process Hazard Assessment Checklist Form
Use this Process Hazard Assessment Checklist to systematically evaluate workplace process hazards and identify areas for improvement.
Which types of hazards are present in the process? (Select all that apply)
*
Chemical exposure
Fire or explosion
Mechanical failure
Electrical hazards
Ergonomic risks
Environmental release
Other
Rate the likelihood of a process hazard occurring.
*
Very unlikely
1
2
3
4
Very likely
5
1 is Very unlikely, 5 is Very likely
Rate the potential severity of consequences if a process hazard occurs.
*
Minor
1
2
3
4
Severe
5
1 is Minor, 5 is Severe
Are existing control measures adequate?
*
Yes, fully adequate
Partially adequate
Not adequate
Not applicable
Is there a documented emergency response plan for this process?
*
Yes
No
In development
When was the last incident or near-miss related to this process?
Please Select
Within the past month
Within the past 6 months
Within the past year
Over a year ago
No known incidents
Process Hazard Risk Assessment Matrix
Rows
Likelihood
Severity
Controls in Place
Primary process hazard
1
2
3
Secondary process hazard
4
5
6
What additional actions are recommended to reduce process hazards?
Assessment completed by (name or team):
*
Date of assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Assessment
Should be Empty: