HAZARD ASSESSMENT FORM

Assessment type: Task In-Home Soldering Location (rooms): (provide your address) Date of initial assessment: (current date)
Department/Program: Information Systems Technology School/Division: SAST Date Reviewed/Revised:

RISK LEVEL RISK LEVEL

(pre-control) (post-control)

TASKS / ACTIVITIES HAZARD CONTROL

POTENTIAL HAZARD HAZARD CONTROLS ADDITIONAL COMMENTS

LIKELIHOOD

LIKELIHOOD
SEVERITY

SEVERITY
CATEGORY TYPE

(1 - 3)

(1 - 3)

(1 - 3)

(1 - 3)
SXL

SXL
RISK

RISK
0 0

0 0

0 0

0 0

Soldering 0 0

0 0

0 0

HS.FRM.15 - Hazard Assessment Form Rev.2 Page 1 of 6

 HAZARD ASSESSMENT FORM

0 0

0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

ADDITIONAL COMMENTS / DETAILS

HS.FRM.15 - Hazard Assessment Form Rev.2 Page 2 of 6

 HAZARD ASSESSMENT FORM

Created By:
Employee’s name (Print): (Provide your name) Title: Student

Employee’s name (Print): Title:

Employee’s name (Print): Title:

Employee’s name (Print): Title:

Employee’s name (Print): Title:

Employee’s name (Print): Title:

Reviewed By:
Title:
Health and Safety Services

Approved By:

LOW - MEDIUM POST-CONTROL RISK

Supervisor/Manager Name (printed) Supervisor/Manager Signature Date:

HIGH POST-CONTROL RISK

Next Level Approval Name (printed) Next Level Approval Signature Date:

HS.FRM.15 - Hazard Assessment Form Rev.2 Page 3 of 6

 HAZARD CATEGORY
Chemical Ergonomic Physical Psychological Biological
Spill potential Heavy lifting / overexertion Compressed Gases Violence/Abuse Contact with animals
Fumes/Vapours Awkward body position / pressure points Pressure (pneumatic/hydraulic/water) Bullying Exposure to infectious material
Hazardous waste Repetitive bending / twisting Radiation (Ionizing/ Non-ionizing) Harassment Exposure to blood and body fluid
Pesticides Working above your head Gripping / Pinch Points Mental stress Insect/Animal bite
Pressurized Gas Repetitive movement Mechanical (rotating equipment) Language barriers Human/Animal waste
Flammable liquids Prolonged sitting / standing Fire / explosion Working workload demands Mold/Fungi
Dust/particulate (silica, asbestos) Improperly adjusted workstation and chairs Lock-Out / Tag-Out Sexual harassment Plants
Unidentified liquids Inappropriate or inadequate tools Working at Heights Substance abuse Waste water sewer
Detergents/disinfectant Vibration (excessive) Heat stress/ Cold Exposure Fatigue/sleep depravation Needlestick with BBFE
Volatile Organic Compound (VOC) Laboratory activity (pipetting, microscopy) Inadequate Lighting Shift work / prolonged working hrs.
Corrosive chemical Repetitive stress injury Noise Levels Work/life conflict
Toxic chemicals Eye Strain Ventilation Working Alone
Oil / Petroleum Housekeeping
Mercury Wildlife
Latex Slip/ Trip / Fall
Oxidizing Chemicals Limited Access/ Egress
Arosol Restricted Work Place
Wood Dust Inappropriate machine guarding
Flash arc
Wet surface condition
Weather conditions
Electrical Cords
Physical Limitations
Manual Material Handling
Power/Hand tools
Sharp Objects
Falling Objects
Temperature extremes
Working Alone
Working with cash
Working with/around public
Laser
Vehicle in motion
Electromagnetic
Needlestick without BBFE
 RISK RANKING

SEVERITY 1 SEVERITY 2 SEVERITY 3

(Minor) (Critical) (Catastrophic)

Serious injuries that require medical aid through urgent

Near miss, first aid, or emergency room treatment that does not Death or multiple injuries that pose threat to life or can cause
care/emergency room/clinic visit or requiring admission or follow-on
result in admission. permanent disability
care.

LIKELIHOOD 1 LIKELIHOOD 2 LIKELIHOOD 3

(Unlikely) (Might happen) (Highly likely)

Not likely to occur in normal circumstances Might occur at some time in the future Expected to occur regularly under normal circumstances

PRIORITY RANKING

LOW RISK (1-2) MEDIUM RISK (3-4) HIGH RISK (6-9)

Continued operation with proper controls. Monitor the hazard Immediate action to eliminate the risk or implement appropriate
Take timely action to implement appropriate controls to lower or
and take action if the degree of risk increases. Use of controls to lower the degree of risk to a level as low as
minimize the degree of risk. Use engineering or a combination of
administrative and/or PPE control methods may be considered reasonably achievable. Use engineering or a combination of
control methods
to reduce risk. control methods. Interim solutions may be used.

Severity
1 2 3

Make you Send you to Kill you/cause

uncomfortable the hospital permanent
disability

1 Unlikely 1 2 3
Likelihood

Might
2 happen 2 4 6

3 Highly likely 3 6 9
 RECOMMENDED CONTROLS
ELIMINATION SUBSTITUTION ENGINEERING ADMINISTRATIVE PPE
At the Source Along the path At the worker
Enclosure Adequate Supervision Eye protection
Guarding Information (signs and labels) Face Protection
Segregation Purchasing Standards Head
Ventilation-Local Safe Work Procedures Hearing Protection
Ventilation-General Scheduling/Shift Rotation Respiratory
Training/Education Feet
Other Gloves
Lab Coats
Coveralls
Other

HAZARD ASSESSMENT TYPE

Job
Task
Process
Project