Personal Risk Assessment

Name *

Date *

Task *

Is there a procedure for this task? *

Yes

No

Am I familiar with the procedure? *

Yes

No

Am I authorised and/or deemed competent to complete the task? *

Yes

No

Do I have the correct tools and equipment? *

Yes

No

Am I aware of all hazards, including any manual handling risks in my work area and associated controls? *

Yes

No

Will the controls protect me and my workmates from harm? *

Yes

No

Have I communicated identified hazards to surrounding workmates? *

Yes

No

Can I complete the task without deviating from the procedure or JHA? *

Yes

No

If any NO is check, DO NOT commence the task and contact your Supervisor immediately.

Signature *

Why 'No'

Action Taken

Employee Signature

Supervisors Signature