STUDENT PRACTICAL ACTIVITY ORDER FORM AND RISK ASSESSMENT

Name:       Date req’d:       Est finish date      

Supervising Teacher:       Class Name:       Period:       Location:      
Activity Title:      
Hypothesis being tested:      
Materials/ Equipment requested:
Quantity Item Quantity Item
                       
                       
                       
State the appropriate disposal method for all chemicals/ waste being produced:      

HAZARD IDENTIFICATION RISK EVALUATION

What could cause What type of risk is associated with this activity? Risk What should I do? New
harm? (Hazard Identification) Scor Control Measures and/or Risk
(Risk Source) e Management Strategies Score1
STUDENT Experienced Intermediate Novice                 
CAPABILITY  
CLASSROOM Contact Noise Slip                 
Moving parts Fall Posture  
Collision Sharps Impact
SURFACE Carpet Grass Synthetic                 
Cliff/slope Padded Wood  
Concrete Slippery Uneven
BIOLOGICAL Pathogenic Infectious Bite/sting                 
Micro- Blood Airborne  
Bodily fluids Penetrating Venom
Contaminant Poisonous Spine/ prickle
MANUAL HANDLING Environment Repetition Special needs                 
Design Force Stability  
Shape Posture Temperature
Weight Personal Grip
ELECTRICAL Burns Current Shock                 
Cold Heat Voltage  
ENVIRONMENTAL Moving water Terrain Weather                 
Standing  
MECHANICAL Heat Projectiles Noise                 
Moving parts Ventilation Vibration  
Vacuum Pressure
PENETRATING Blunt trauma Sharp trauma                 
OBJECT  
PHYSICAL Absorption Exposure Ingestion                 
Dehydration Injury Inhalation  
Fatigue Visual Temperature
RADIATION Arc flashes Medical Magnetic field                 
Ionising Laser Radioactive  
Microwave Sunburn UV
Infra Red X-rays
GAS Burns Inhalation Bunsen hose                 
Bunsen hose contact with flame secured onto  
turret
EXPLOSION Noise Pressure Exposure                 
Fire Explosion  
OTHER (specify)                       
 

1
Risk Scores – 9-10 Extreme Risk. Do not proceed. Substitute or eliminate. 7-8 High Risk: Principal authorisation required. Substitute or eliminate.
5-6 Moderate Risk: HOD/HOF signature required. Consider implementing further risk controls 2-4 Low Teacher signature
required.
 STUDENT PRACTICAL ACTIVITY ORDER FORM AND RISK ASSESSMENT
CHEMICAL REQUIRMENTS AND CHEMICAL RISK ASSESSMENT
Chemical Name Hazard Identification2 Hazard Statements Precautionary Risk What should I do? New
(include volume and (Colour coded border) (refer to MSDS) Statements Score (Control measures/ Risk
concentration required) (refer to MSDS) Management Strategies) Score
                                         

                                         

                                         

                                         

                                         

                                         

                                         

                                         

2
Chemical Hazard Identification – refer to MSDS
Hazardous Irritant Toxic Corrosiv Flammabl Spills Body Sensitisin Mutagen Environmental toxin Asphyxiant
Combustion Explosive Reactive Harmful Oxidising Splashes Burns Carcinoge Teratogenic Hazardous by Other

Additional notes:      

In completing this request the student acknowledges that they have reviewed the appropriated MSDS material and have been shown how to safely
conduct the relevant procedures required for the safe completion of this activity. The Teacher acknowledges that they have reviewed the appropriate
Standard Operating Procedure/s, Plant and Equipment Risk Assessment/s, MSDS, Hazardous Substances Risk Assessments and EPPR module/s and
provided appropriate induction for the student.

Student Name: …………………………………………………………………. Signature: …………………………………………… Date: ………………………..

Teacher Name: ………………………………………………………………… . Signature: ………………………………………….. Date: ………………………..

HOD (Risk Score 5 and above) Name: ………………………………………. Signature: …………………………………………… Date: ………………………..

Principal (Risk Score 7 and above): Name: …………………………………..Signature: …………………………………………… Date: ………………………..

1
Risk Scores – 9-10 Extreme Risk. Do not proceed. Substitute or eliminate. 7-8 High Risk: Principal authorisation required. Substitute or eliminate.
5-6 Moderate Risk: HOD/HOF signature required. Consider implementing further risk controls 2-4 Low Teacher signature
required.