Department: Service: Reference: Activity: Site: People at Risk: Additional Information: Name of Person Completing Form: Job Date: Review Date: Hazard Risk Existing Control Measures Additional Action Required Initial Final Rating Rating (action by whom and completion date use – L, M, H L, M, H separate Action Plan if necessary)
Department: Service: Reference: Activity: Site: People at Risk: Additional Information: Name of Person Completing Form: Job Date: Review Date: Hazard Risk Initial Rating L, M, H Existing Control Measures Final Rating L, M, H Additional Action Required (action by whom and completion date – use separate Action Plan if necessary)