RA No.

Risk Assessment Form

Location

Item No. of Pages

Processes Preparation Date: July 11, 2019
Risk Assessment RA Conducted By Next review July 11, 2020
Team Date:
Approved By: Prepared By Reviewed By: MI Management
RM Leader
Hazard Identification Risk Evaluation Risk Control
No. Task Sequence Hazards Possible Risks Risk Control Additional Control Action

Likelihood

Severity

Risk level
level
Significance

Likelihood

Severity

Risk level

level
Significance
Accident/Ill Measures Status
Health

Consequence
Likelihood
1-Insignificant 2-Minor 3-Moderate 4-Major 5-Catastrophic Hierarchy of Control
5 Almost certain 5 10 15 20 25 Elimination Category Risk Rating
4 Likely 4 8 12 16 20 Substitution High 15 – 25
3 Possible 3 6 9 12 15 Engineering Medium 5 – 12
2 Unlikely 2 4 6 8 10 Administrative Low 1–4
1 Rare 1 2 3 4 5 Personal Protective Equipment (PPE)
 RA No.
Risk Assessment Form
Location

Item No. of Pages

Processes Preparation Date: July 11, 2019
Risk Assessment RA Conducted By Next review July 11, 2020
Team Date:
Approved By: Prepared By Reviewed By: MI Management
RM Leader
Hazard Identification Risk Evaluation Risk Control
No. Task Sequence Hazards Possible Risks Risk Control Additional Control Action

Likelihood

Severity

Risk level
level
Significance

Likelihood

Severity

Risk level

level
Significance
Accident/Ill Measures Status
Health

Consequence
Likelihood
1-Insignificant 2-Minor 3-Moderate 4-Major 5-Catastrophic Hierarchy of Control
5 Almost certain 5 10 15 20 25 Elimination Category Risk Rating
4 Likely 4 8 12 16 20 Substitution High 15 – 25
3 Possible 3 6 9 12 15 Engineering Medium 5 – 12
2 Unlikely 2 4 6 8 10 Administrative Low 1–4
1 Rare 1 2 3 4 5 Personal Protective Equipment (PPE)
 RA No.
Risk Assessment Form
Location

Item No. of Pages

Processes Preparation Date: July 11, 2019
Risk Assessment RA Conducted By Next review July 11, 2020
Team Date:
Approved By: Prepared By Reviewed By: MI Management
RM Leader
Hazard Identification Risk Evaluation Risk Control
No. Task Sequence Hazards Possible Risks Risk Control Additional Control Action

Likelihood

Severity

Risk level
level
Significance

Likelihood

Severity

Risk level

level
Significance
Accident/Ill Measures Status
Health

Consequence
Likelihood
1-Insignificant 2-Minor 3-Moderate 4-Major 5-Catastrophic Hierarchy of Control
5 Almost certain 5 10 15 20 25 Elimination Category Risk Rating
4 Likely 4 8 12 16 20 Substitution High 15 – 25
3 Possible 3 6 9 12 15 Engineering Medium 5 – 12
2 Unlikely 2 4 6 8 10 Administrative Low 1–4
1 Rare 1 2 3 4 5 Personal Protective Equipment (PPE)
 RA No.
Risk Assessment Form
Location

Item No. of Pages

Processes Preparation Date: July 11, 2019
Risk Assessment RA Conducted By Next review July 11, 2020
Team Date:
Approved By: Prepared By Reviewed By: MI Management
RM Leader
Hazard Identification Risk Evaluation Risk Control
No. Task Sequence Hazards Possible Risks Risk Control Additional Control Action

Likelihood

Severity

Risk level
level
Significance

Likelihood

Severity

Risk level

level
Significance
Accident/Ill Measures Status
Health

Consequence
Likelihood
1-Insignificant 2-Minor 3-Moderate 4-Major 5-Catastrophic Hierarchy of Control
5 Almost certain 5 10 15 20 25 Elimination Category Risk Rating
4 Likely 4 8 12 16 20 Substitution High 15 – 25
3 Possible 3 6 9 12 15 Engineering Medium 5 – 12
2 Unlikely 2 4 6 8 10 Administrative Low 1–4
1 Rare 1 2 3 4 5 Personal Protective Equipment (PPE)