This questionnaire is designed to help identify potential risks and hazards in your workplace. Please answer all questions honestly and thoroughly. Your responses will help us create a safer work environment for everyone.
Department/Area
Date of Assessment
Location
Assessor Name
Assessor Title
Brief description of the work activities performed in this area.
For each of the following categories, please identify any potential hazards present in the workplace. Be specific and describe the hazard, not just the category.
Noise: Describe any excessive or disruptive noise sources. (e.g., loud machinery, constant ringing phones).
Vibration: Describe any sources of vibration. (e.g., vibrating tools, machinery).
Radiation: Describe any potential sources of radiation (e.g., lasers, X-ray equipment)
Temperature Extremes: Describe any areas with excessively hot or cold temperatures.
Lighting: Describe any inadequate or excessive lighting. (e.g., glare, shadows, insufficient light)
Slips, Trips, and Falls: Describe any potential tripping hazards (e.g., uneven floors, cords, spills).
Ergonomic Hazards: Describe any awkward postures, repetitive motions, or heavy lifting.
Machinery & Equipment: Describe any potential hazards associated with machinery or equipment (e.g., unguarded moving parts, sharp edges).
Electricity: Describe any potential electrical hazards (e.g., exposed wiring, damaged cords).
Fire & Explosion: Describe any potential fire or explosion hazards (e.g., flammable materials, ignition sources).
Confined Spaces: Describe any confined spaces and potential hazards within them.
Working at Heights: Describe any work performed at heights and potential fall hazards.
Vehicle Traffic: Describe any internal vehicle traffic and potential hazards.
Dusts: Describe any hazardous dusts (e.g., wood dust, silica dust).
Fumes & Vapors: Describe any hazardous fumes or vapors (e.g., chemical solvents, welding fumes).
Gases: Describe any hazardous gases (e.g., natural gas, propane).
Liquids: Describe any hazardous liquids (e.g., acids, corrosives).
Flammable Materials: Describe any flammable or combustible materials.
Infectious Agents: Describe any potential exposure to infectious agents (e.g., bacteria, viruses).
Mold: Describe any presence of mold.
Animals & Insects: Describe any potential hazards from animals or insects.
Stress: Describe any workplace stressors (e.g., high workload, tight deadlines).
Violence: Describe any potential for workplace violence.
Harassment: Describe any potential for workplace harassment.
Bullying: Describe any potential for workplace bullying.
Work-Life Balance: Describe any factors affecting work-life balance that could pose a risk.
For EACH hazard identified in Section 2, please complete the following:
Create a table with question:
Physical Hazards:
Description | Noise | Vibration | Radiation | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Hazard Description (e.g., Unguarded saw blade) | ||||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | ||||
3 | How could they be harmed? (e.g., Laceration, amputation) | ||||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | ||||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | ||||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | ||||
7 | Existing Controls (e.g., Training provided) | ||||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
Physical Hazards (continued):
Description | Temperature Extremes | Lighting | Slips, Trips, and Falls | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Hazard Description (e.g., Unguarded saw blade) | ||||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | ||||
3 | How could they be harmed? (e.g., Laceration, amputation) | ||||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | ||||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | ||||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | ||||
7 | Existing Controls (e.g., Training provided) | ||||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
Physical Hazards (continued):
Description | Ergonomic Hazards | Machinery & Equipment | Electricity | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Hazard Description (e.g., Unguarded saw blade) | ||||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | ||||
3 | How could they be harmed? (e.g., Laceration, amputation) | ||||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | ||||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | ||||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | ||||
7 | Existing Controls (e.g., Training provided) | ||||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
Physical Hazards (continued):
Description | Fire & Explosion | Confined Spaces | Working at Heights | Vehicle Traffic | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Hazard Description (e.g., Unguarded saw blade) | |||||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | |||||
3 | How could they be harmed? (e.g., Laceration, amputation) | |||||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | |||||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | |||||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | |||||
7 | Existing Controls (e.g., Training provided) | |||||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
Chemical Hazards
Description | Dust | Fumes & Vapors | Gases | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Hazard Description (e.g., Unguarded saw blade) | ||||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | ||||
3 | How could they be harmed? (e.g., Laceration, amputation) | ||||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | ||||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | ||||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | ||||
7 | Existing Controls (e.g., Training provided) | ||||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
Chemical Hazards (continued):
Description | Liquids | Flammable Materials | ||
|---|---|---|---|---|
A | B | C | ||
1 | Hazard Description (e.g., Unguarded saw blade) | |||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | |||
3 | How could they be harmed? (e.g., Laceration, amputation) | |||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | |||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | |||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | |||
7 | Existing Controls (e.g., Training provided) | |||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
Biological Hazards:
Description | Infectious Agents | Mold | Animals & Insects | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Hazard Description (e.g., Unguarded saw blade) | ||||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | ||||
3 | How could they be harmed? (e.g., Laceration, amputation) | ||||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | ||||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | ||||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | ||||
7 | Existing Controls (e.g., Training provided) | ||||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
Psychosocial Hazards:
Description | Stress | Violence | Harassment | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Hazard Description (e.g., Unguarded saw blade) | ||||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | ||||
3 | How could they be harmed? (e.g., Laceration, amputation) | ||||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | ||||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | ||||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | ||||
7 | Existing Controls (e.g., Training provided) | ||||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
Psychosocial Hazards (continued):
Description | Bullying | Work-Life Balance | ||
|---|---|---|---|---|
A | B | C | ||
1 | Hazard Description (e.g., Unguarded saw blade) | |||
2 | Who could be harmed? (e.g., Machine operator, nearby workers) | |||
3 | How could they be harmed? (e.g., Laceration, amputation) | |||
4 | Likelihood (1 = Low, 2 = Medium, 3 = High) | |||
5 | Severity (1 = Low, 2 = Medium, 3 = High) | |||
6 | Risk Level (1 = Low, 2 = Medium, 3 = High) | |||
7 | Existing Controls (e.g., Training provided) | |||
8 | Recommended Actions (e.g., Install guard, enforce PPE) |
What control measures are currently in place to mitigate identified risks?
Are these control measures adequate?
Yes
No
Partially
What additional control measures are recommended?
Who is responsible for implementing these control measures?
What is the timeline for implementation?
Signatures of assessor
Important Notes:
This comprehensive questionnaire will help you systematically identify, assess, and control workplace hazards. Remember, a safe workplace is everyone's responsibility.
Questionnaire Template Insight
Please remove this Questionnaire template insight section before publishing.
This Risk Assessment Questionnaire is a crucial tool for proactively identifying and mitigating potential dangers in the workplace. It's designed to be comprehensive and systematic, guiding assessors through a thorough evaluation process. Here's a breakdown of its key aspects:
1. Structured Approach: The questionnaire follows a logical flow, starting with general workplace information and progressing to hazard identification, risk assessment, control measures, and follow-up. This structured approach ensures that all critical areas are considered.
2. Broad Hazard Coverage: It covers a wide spectrum of potential hazards, categorized as physical, chemical, biological, and psychosocial. This holistic approach recognizes that workplace risks can stem from various sources, not just the obvious physical dangers. This is a significant strength as many risk assessments focus too heavily on physical risks.
3. Detailed Hazard Identification: The questionnaire encourages specific descriptions of hazards rather than just listing categories. This level of detail is essential for accurate risk assessment and developing effective control measures. For example, instead of just saying "Machinery," it asks for details like "Unguarded saw blade on the table saw."
4. Risk Assessment Matrix: The inclusion of a risk assessment matrix (Likelihood x Severity = Risk Level) provides a standardized method for evaluating the level of risk associated with each identified hazard. This helps prioritize hazards and allocate resources effectively. This is a critical component of any risk assessment.
5. Focus on Control Measures: The questionnaire emphasizes the importance of implementing control measures to mitigate risks. It asks about existing controls, their effectiveness, and recommendations for additional controls. This focus on action is crucial for preventing accidents and injuries. It's not enough to just identify risks; you have to control them.
6. Responsibility and Timeline: By asking about who is responsible for implementing control measures and the timeline for implementation, the questionnaire promotes accountability and ensures that actions are taken promptly.
7. Review and Follow-up: The inclusion of a section for review and follow-up highlights the ongoing nature of risk assessment. Risks and conditions can change, so regular reviews are essential to maintain a safe work environment. This reinforces that risk assessment is not a one-time event.
8. Employee Involvement (Implied): While not explicitly stated in every section, the process of risk assessment ideally involves consultation with employees who are most familiar with the work tasks and potential hazards. This is best practice and should be explicitly included in the process.
9. Actionable Outcomes: The ultimate goal of this questionnaire is to generate actionable outcomes. By identifying hazards, assessing risks, and recommending control measures, it provides a roadmap for creating a safer and healthier workplace.
In summary, this questionnaire provides a robust framework for conducting comprehensive risk assessments. Its structured approach, broad hazard coverage, detailed hazard identification, risk assessment matrix, focus on control measures, and emphasis on follow-up make it a valuable tool for any organization committed to workplace safety. However, it is important to remember that this is a template. It should be customized to the specific workplace and the nature of the work being performed. Furthermore, the process of using the questionnaire should include input from workers and supervisors.
To configure an element, select it on the form.