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PCBU Risk Assessment Template

Hazard identification, risk evaluation and hierarchy of controls per WHS Act 2011 Section 17.

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Assessment Details

Risk Matrix (Likelihood x Consequence)

Likelihood \ Consequence 1 - Insignificant 2 - Minor 3 - Moderate 4 - Major 5 - Catastrophic
5 - Almost certainMHHEE
4 - LikelyMMHHE
3 - PossibleLMMHH
2 - UnlikelyLLMMH
1 - RareLLLMM

Hazard Register & Risk Rating

Identify each hazard. Rate inherent risk (before controls) using the matrix above. Record hierarchy level and control measure. Rate residual risk (after controls).

# Hazard Description Who Is Exposed L C Inherent Risk Hierarchy Level Control Measure L C Residual Risk
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Hierarchy of Controls Reference
E = Eliminate  |  S = Substitute  |  I = Isolate  |  Eng = Engineering controls  |  A = Administrative controls  |  P = PPE
Always start at the top of the hierarchy. Lower-order controls are only acceptable when higher-order controls are not reasonably practicable.
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Assessment Ref
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PCBU Risk Assessment - Page 2 of 2
Assessment Ref
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Assessor

Action Plan

For each control measure, record the responsible person, implementation date and verification method.

# Control Measure Responsible Person Due Date Completed Verification Method Verified
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Review Schedule & Triggers
Early review triggers: incident or near miss related to this task, change to the work activity or process, new hazard identified, control measures found to be ineffective, worker consultation raises new concerns, new legislative or code of practice requirements.

Declaration

I declare that this risk assessment has been conducted in accordance with the WHS Act 2011 Section 17 (reasonably practicable) and Section 19 (primary duty of care). All hazards associated with the assessed activity have been identified in consultation with workers. Risk levels have been rated before and after controls using the risk matrix. Controls have been selected following the hierarchy of controls. Responsible persons and due dates have been assigned for each control measure. I will communicate the findings to all affected workers and schedule a review as noted above.

Assessor Sign-off
Signature
Print name
Date
PCBU / Manager Approval
Signature
Print name
Date

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Free template from MapTrack. For digital risk assessments with hierarchy-of-controls prompts, photo capture and automated review scheduling, see maptrack.com