Safety Form : HSE-RA(3A)

ACTIVITY-BASED RISK ASSESSMENT FORM

Department Project Safety Conducted By;(Name, Designation, Date, Signature Approve By; Ref
Process/Activities RA Leader No.
Signature; 01/P
Project/Location RA Member 1 HL

Original RA Member 2 Name;

Assessment date
Last Review Date RA Member 3 Designation;

Next Review Date RA Member 4 Date;

Hazard Identification Risk Evaluation Risk Control

N Work Hazards & Existing Risk Seve Likeli R Additional Risk seve Likeli R Implement Due Rem
o Activities Possible Controls rity hood P Control rity hood P ation Date/ arks
. Injury/Ill-health (if any) N N Person/ Follow
Person-at-risk Action Up date
Officer
1

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 Safety Form : HSE-RA(3A)

#RPN = Risk Prioritization Number

Likelihood Remote (1) Occasional (2) Frequent (3)

Severity
Major (3) Medium (3) High (6) High (9)
Moderate (2) Low (2) Medium (4) High (6)
Minor (1) Low (1) Low (2) Medium (3)

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