Document Reference : Mideast / FMS

Revision No: 012 / Sept 2022

Section: 3
Company Forms Manual RISK ASSESSMENT REPORT
Vessel: Date: 12-Aug-16
Seq No. Risk Assessment Led By:
Task: Personnel involved in the task:
Initial Risk Assessment Subsequent Risk Reduction/Elimination Measures
Risk Assessment Actions Risk Assessment
Likelihood Severity Risk Rank Required Additional Control Measures Likelihood Severity Risk Rank Action Date Action By
Hazard (1,2,3,4,5) (1,2,3,4,5) (VH, H, M,L) (1,2,3,4,5) (1,2,3,4,5) (VH, H, M,L)
No Hazards Existing control measures
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Office Review Shipboard Assessment Team(Ranks):
Date Comments Signature

List out possible contingencies / unplanned occurrences discussed

Declaration: In the event where assessors determine that there are no additional measures apparent, the team can conclude the assessment by listing only the existing controls.
(Risk assessment must be discussed with all personnel involved in the Task)
NOTE: To be used in conjunction with the RISK MATRIX provided in Mideast / HSE, Section 10.6

1
Mideast Form No. 109