Algorithmic Impact Assessment Questionnaire Form
Complete this Algorithmic Impact Assessment Questionnaire Form to help evaluate the potential impacts, risks, and governance considerations of your algorithmic system. Please answer each question based on your current understanding and available documentation.
Project or Algorithm Name
*
Briefly describe the primary purpose of this algorithmic system.
*
Which domain best describes the primary application of this algorithm?
*
Please Select
Healthcare
Finance
Human Resources
Public Sector
Retail
Transportation
Other
Select the types of potential impacts this algorithm may have. (Select all that apply)
*
Individual rights or freedoms
Access to services or opportunities
Economic outcomes
Fairness and equity
Transparency or explainability
Other
How likely is it that this algorithm could introduce or amplify bias?
*
Very Unlikely
1
2
3
4
Very Likely
5
1 is Very Unlikely, 5 is Very Likely
Please rate the following aspects of this algorithmic system.
*
Rows
Very Low
Low
Moderate
High
Very High
Potential for unintended consequences
1
2
3
4
5
Transparency and explainability
6
7
8
9
10
Human oversight and intervention
11
12
13
14
15
Accountability mechanisms
16
17
18
19
20
How would you rate the overall risk level associated with this algorithmic system?
*
Very Low
Low
Moderate
High
Very High
Has the algorithm undergone an independent audit or review?
*
Yes
No
Planned
How confident are you that risks and mitigation strategies have been clearly documented?
*
1
2
3
4
5
Please provide any additional comments or context relevant to this assessment.
Submit Assessment
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