S

Site Address

Site Risk Assessment Form RA Ref No:

Assessor Job Title Assessment Date Review Dates / Initials

<<Name>> <<e.g. Foreman>> <<Date>> <<Dates>> <<Initials>>

Assessment task: Working on scaffolding

Persons at risk Details Frequency Are any disabled? Comments

A
Contractors <<e.g. all operatives>> <<e.g. approx 8 hour/day>> Yes No
Visitors Yes No
Gen. Public / Others <<e.g. anyone in the vicinity>> Yes No
Hz Level of Risk
Hazard description How are persons affected? Existing controls Further controls / action
No. P S R
1 Falls from height e.g. Falling from ladders while <<e.g. Ladders used for access only, <<e.g. Operatives to attend work at
climbing to/from upper levels will <<e.g. <<e.g. <<e.g. checked before use>> height course>>
cause major injuries 4>> 4>> 16>>
2 Hit by falling objects e.g. Objects falling from scaffolding <<e.g. Hard hats to be worn around <<e.g. Supervisor to ensure that
or ladders can serious injury to <<e.g. <<e.g. <<e.g. scaffolding, No-one to work under worked debris is removed from scaffolding
those working below 4>> 4>> 16>> scaffolding or ladders>> regularly>>

M
3

Probability (P)
Severity (S)
Risk (R)
5=very likely, 4=likely, 3=quite possible, 2=possible, 1=unlikely
5=fatal, 4=severe, 3=moderate, 2=slight, 1=negligible
P
0-8=low risk, no action required. 9-15=medium risk, ensure adequate controls are in use. 16-25=high risk, stop operation & implement control measures

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