ACTIVITY HAZARDS ANALYSIS

Print Form Overall Risk Assessment Code (RAC)

(Use highest code)
Date: Project:
Risk Assessment Code Matrix
E = Extremely High Risk
Activity:
H = High Risk
Probability
M = Moderate Risk
L = Low Risk Frequent Likely Occasional Seldom Unlikely
Activity Location:
S Catastrophic E E H H M
e
v
Prepared By: e Critical E H H M L
r
i Marginal H M M L L
t
y
Negligible M L L L L

Add Identified Hazards

JOB STEPS HAZARDS ACTIONS TO ELIMINATE OR MINIMIZE HAZARDS RAC

X
X
X

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EQUIPMENT TRAINING INSPECTION

X
X
X
Involved Personnel:

Acceptance Authority (digital signature):

NCTD Work Plan Form July 2015
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