General Risk Assessment Form

A General Risk Assessment form is required, mostly by law in all institutions so as to investigate and or ensure that the health and safety of all individuals in a specific locality is adhered to. This form is also used to check on how previous risks were dealt with and how to avoid them.

PERSONAL DETAILS

Names

First                                      Middle                                         Last

______________                  ______________                        _______________________

Contractor’s reference number _________________________________

Your Contact Address: ____________________ City: _________________ Zip: _____

Telephone: _________________ Office: _____________________ Fax: ________

Social security no: ___________________________________________

EMPLOYMENT DETAILS

Location________________________________

Field of Work______________________

Activity involved __________________________

Kindly answer the following questions with a Yes or No

Do you believe this Company is fit to cater for the health and safety of its employees?______

Have you ever been injured before? _________________________

Have you witnessed any person(s) been injured? _________________

Kindly state their level of injury__________________________________

________________________

State the Safety Precaution measure was taken?___________________________

FOR OFFICIAL USE ONLY

Date______________________

Assessed by

Name ___________________ Signature__________________

Confirmed by

Name _______________________Signature____________________