Hazard Identification and Control FormFill this in on your phone. Tap the boxes and type in the blanks. What you enter is kept on this phone while you work. When you are done, send it to the safety team, or print it.Appendix 6 – Hazard Identification and Control Form [ Church name ] church Hazard identification and control form Instructions: Use this form to document individual hazards, assess risks, and plan control measures. Complete a separate form for each significant hazard identified. Hazard details Field Information Hazard ID: Date Identified: Identified By: Location: Activity/Process: Hazard description What is the hazard? Who could be harmed? StaffVolunteersCongregationVisitorsContractorsChildren How could harm occur? When is exposure likely? DailyWeeklyMonthlyOccasionallyDuring eventsMaintenance Risk assessment Likelihood of Harm: 1 - Rare (may occur only in exceptional circumstances) 2 - Unlikely (could occur at some time) 3 - Possible (might occur at some time) 4 - Likely (will probably occur in most circumstances) 5 - Almost Certain (expected to occur in most circumstances) Consequence of Harm: 1 - Insignificant (no treatment required) 2 - Minor (first aid treatment required) 3 - Moderate (medical treatment required) 4 - Major (serious injury requiring hospital treatment) 5 - Catastrophic (death or permanent disability) Risk Rating: Likelihood × Consequence = Risk Priority: Low (1-4) - Acceptable, monitor and review Medium (5-9) - Tolerable, implement controls as soon as practicable High (10-16) - Unacceptable, implement controls immediately Extreme (17-25) - Intolerable, stop activity until controls are implemented Existing controls What controls are currently in place? Control Type Description Effectiveness Elimination EffectivePartially EffectiveIneffective Substitution EffectivePartially EffectiveIneffective Isolation EffectivePartially EffectiveIneffective Engineering EffectivePartially EffectiveIneffective Administrative EffectivePartially EffectiveIneffective PPE EffectivePartially EffectiveIneffective Additional controls required Hierarchy of Controls Assessment: Can the hazard be ELIMINATED? Yes - Action No - Reason Can the hazard be SUBSTITUTED with something safer? Yes - Action No - Reason Can people be ISOLATED from the hazard? Yes - Action No - Reason Can ENGINEERING CONTROLS be implemented? Yes - Action No - Reason Can ADMINISTRATIVE CONTROLS be implemented? Yes - Action No - Reason Is PERSONAL PROTECTIVE EQUIPMENT required? Yes - Action No - Reason Action plan Action Required Control Type Responsibility Target Date Cost Estimate Priority Total Estimated Cost: $ Funding Source: Implementation Interim Measures (if required): Communication Required: Staff briefingVolunteer trainingSignageProcedure update Congregation noticeOther Training Required: Yes - Details No Monitoring and review How will effectiveness be monitored? Monitoring Frequency: DailyWeeklyMonthlyQuarterlyAnnually Review Date: // Responsible Person: Residual risk assessment After implementing additional controls: New Likelihood: 12345 New Consequence: 12345 New Risk Rating: Is residual risk acceptable? YesNo If No, additional actions required: Approvals Risk Assessment Completed By: Signature: Date: Name: Position: Risk Assessment Reviewed By: Signature: Date: Name: Position: Health & Safety Champion Actions Approved By: Signature: Date: Name: Position: Senior Pastor / Church Manager Implementation record Date Action Completed Completed By Verification All Actions Completed: YesDate: // Verified By: Date: // Review history Review Date Reviewed By Changes Made Next Review Form Status: ActiveUnder ReviewClosed Closure Reason (if applicable): Finished?Website Your name *Send to the safety teamPrint or save as PDF Clear everything