& RISK ASSESSMENT Ra No./ERMS Ref.: Date: Version No.: Review Date: Authorised by: STEP 1 ENTER INFORMATION ABOUT THE ACTIVITY/TASK, ITS LOCATION AND THE PEOPLE COMPLETING THE – Location name: Building No.: Room No.: Date: Assessed by: HSR/Employee representative: Chemical (Manufacturer’s name and product name): Is the chemical a hazardous substance? If list the hazard statement: “yes” Yes No Is the chemical a dangerous good? If list the dangerous goods class: Is the chemical a scheduled poison? If list the poison schedule: “yes” “yes” Yes No Yes No Description of work/activities/use: Are there any licencing/permit requirements? If provide details: Health surveillance requirements (list if not required): A current SDS is available “yes” “nil” Yes No Yes Exposure route of chemical: Inhalation Skin (absorption) Eye Ingestion Injection Other Specify: – Workplace conditions (Describe layout and physical conditions - including access and egress): What are the storage requirements? What are the waste/disposal requirements? List systems of work for the activity/task: Training Inspections ● ● SOPs Existing controls ● ● Emergency situations ● Is there past experience with the chemical that may assist in the assessment? Existing controls SOPs Standards ● ● ● Industry standards Incidents & near-hits Legislation & Codes ● ● ● Training Incident Investigation Guidance material ● ● ● First aid and emergency requirements Additional first aid kit contents Special first aid requirements (eg oxygen) ● ● Emergency eyewash Emergency shower ● ● Spill kit Neutralising agent Restrict access ● ● ●
& Ra No./ERMS Ref.: Date: Version No.: Review Date: Authorised by: STEP 1 – ENTER INFORMATION ABOUT THE ACTIVITY/TASK, ITS LOCATION AND THE PEOPLE COMPLETING THE RISK ASSESSMENT Location name: Building No.: Room No.: Date: Assessed by: HSR/Employee representative: Chemical (Manufacturer’s name and product name): Is the chemical a hazardous substance? Yes No If “yes” list the hazard statement: Is the chemical a dangerous good? Yes No If “yes” list the dangerous goods class: Is the chemical a scheduled poison? Yes No If “yes” list the poison schedule: Description of work/activities/use: Are there any licencing/permit requirements? Yes No If “yes” provide details: Health surveillance requirements (list “nil” if not required): A current SDS is available Yes Exposure route of chemical: Inhalation Skin (absorption) Eye Ingestion Injection Other – Specify: Workplace conditions (Describe layout and physical conditions - including access and egress): What are the storage requirements? What are the waste/disposal requirements? List systems of work for the activity/task: ● Training ● Inspections ● SOPs ● Existing controls ● Emergency situations Is there past experience with the chemical that may assist in the assessment? ● Existing controls ● SOPs ● Standards ● Industry standards ● Incidents & near-hits ● Legislation & Codes ● Training ● Incident Investigation ● Guidance material First aid and emergency requirements ● Additional first aid kit contents ● Special first aid requirements (eg oxygen) ● Emergency eyewash ● Emergency shower ● Spill kit ● Neutralising agent ● Restrict access
Chemical-risk-assessment-form.docx