Specimen form for documenting the results of the assessment

Specimen form for documenting the results of the occupational risk assessment

Company (department)WORK POST
Date card number
Prepared by
Work post

Forename and surname of the worker/workers
No. Threat Measures reducing occupational risk Estimate / assessment of occupational risk Recommendations on the introduction of additional protective measures
  Write here all the identified threats, which could result in injuries or diseases to the workers, e.g.:
- noise
- infrasound or ultrasound noise
- vibrations (positional or general)
- microclimate (cold or hot)
- radiation (infrared, ultraviolet, laser)
- electromagnetic field
- machines in motion
- moving components
- sharp, protruding, coarse elements
- fluids under pressure
- slippery, uneven surfaces
- restricted areas (approaches, entrances, accesses)
- threat of explosion and fire
- low voltage
- high voltage
- biological agents (viruses, bacteria and others)
- static loads
- monotony
- physical exertion
- psychological load
- moderate microclimate
- lighting (intense, dazzling, uniformity, pulsing)
List here the measures that are applied in order to reduce occupational risk related to every identified threat - collective protective equipment (e.g. ventilation), personal protective equipment (e.g. hearing protectors), instructions on safe work, training etc. Write here - for every identified threat - the result of the estimate of the occupational risk and its assessment following the application of the protective measures mentioned (e.g. "medium risk / permissible" or "large risk / not permissible") Write here the activities that are planned to reduce occupational risk. These activities must be implemented in the shortest possible time if the occupational risk is not permissible.
Confirmation of receipt of the information by the worker(s) Signature(s) Date

See also:


Module of the STER System supporting selection of personal protective equipment