WORKPLACE ASSESSMENT SHEET

ATTACH
New Substance MSDS
Upgraded MSDS MSDS Review or generic review sheet
Chemical Hazard JSA/SWMS
HAZARDOUS SUBSTANCES AND SUBSTANCES WITH HEALTH RISKS Label
Product ID Dangerous Goods (if applicable)
Observations, Recommendations and Actions form (ORA) (and Relative Level of Risk) to be used Dangerous Goods Risk Assessment
to record and prioritise risk control actions (if applicable)

SUBSTANCE/S: DATE:

COMPANY: LOCATION: AREA:

WHAT ACTIVITY AND WHAT EXPOSURE ROUTE? WHAT ACTIVITY AND WHAT EXPOSURE ROUTE?

1. Opening Containers / Hooking up Hoses / Oral Eye 2. Passive Exposure Welding Fumes / Oral Eye
Decanting / Dosing Aerosols from processes (sewage) / dusts /
Skin Inhalation particulates Skin Inhalation
What Substances What Substances?
Frequent Infrequent Frequent Infrequent
exposure exposure exposure exposure

Time per Time per

day/shift day/shift

3. Surface coating using hand held sprays Oral Eye 4. Surface coating using Aerosols Oral Eye

Skin Inhalation Skin Inhalation

What Substances? What Substances?
Frequent Infrequent Frequent Infrequent
exposure exposure exposure exposure

Time per Time per

day/shift day/shift
WHAT ACTIVITY AND WHAT EXPOSURE ROUTE? WHAT ACTIVITY AND WHAT EXPOSURE ROUTE?

5. Surface coating (Brush) Oral Eye 6. Transporting - Spills / Ruptures Oral Eye

Skin Inhalation Skin Inhalation

What Substances? What Substances?
Frequent Infrequent Frequent Infrequent
exposure exposure exposure exposure

Time per Time per

day/shift day/shift

7. Storing and Handling - Spills / Ruptures Oral Eye 8. Mixing / Testing / Blending Oral Eye

Skin Inhalation Skin Inhalation

What Substances? What Substances?
Frequent Infrequent Frequent Infrequent
exposure exposure exposure exposure

Time per Time per

day/shift day/shift

9. Other Oral Eye 10. Other Oral Eye

Skin Inhalation Skin Inhalation

What Substances? What Substances?
Frequent Infrequent Frequent Infrequent
exposure exposure exposure exposure

Time per Time per

day/shift day/shift
 ARE RISK CONTROLS ARE RISK CONTROLS
RISK CONTROLS IN PLACE RISK CONTROLS IN PLACE
Yes No Unsure Yes No Unsure
Is personal safety equipment (PPE) provided in accordance with
Is PPE recorded, inspected and maintained properly? - safety
MSDS Review? (If MSDS review requirement is modified by this
shower / eyewashes / respiratory protection / local exhaust / air
assessment say how and why) Include safety showers/eyewashes
flows or mechanical ventilation e.g. SCBA canister masks?
(proper pressure) and in the right place (<2m not >7 to 10m)
Comments: Comments:

Activity No. Activity No.

All 1 2 3 4 5 6 7 8 9 All 1 2 3 4 5 6 7 8 9

Is earthing and bonding in place for static electricity controls for Is specific guidance and spill control media available for emergency
decanting of Class 3 flammable liquids? spill or rupture?
Comments: Comments:

Activity No. Activity No.

All 1 2 3 4 5 6 7 8 9 All 1 2 3 4 5 6 7 8 9

Is any equipment in hazardous zones (where Class 3 are stored or Has appropriate training been provided and recorded in the HR
handled) inspected, tested and maintained? system (including this assessment?
Comments: Comments:

Activity No. Activity No.

All 1 2 3 4 5 6 7 8 9 All 1 2 3 4 5 6 7 8 9
 ARE RISK CONTROLS ARE RISK CONTROLS
RISK CONTROLS IN PLACE RISK CONTROLS IN PLACE
Yes No Unsure Yes No Unsure
Are all safety related controls, alarm systems recorded, regularly
Are safe working procedures written and promulgated?
inspected and maintained?
Comments: Comments:

Activity No. Activity No.

All 1 2 3 4 5 6 7 8 9 All 1 2 3 4 5 6 7 8 9

If visitors or contractors can come in contact with the substances on

Is appropriate safety signage provided?
Site are they advised of the risks?
Comments: Comments:

Activity No. Activity No.

All 1 2 3 4 5 6 7 8 9 All 1 2 3 4 5 6 7 8 9

Has all plant associated with the use of dangerous goods /

Have health surveillance requirements been identified?
hazardous substances been subject to plant safety risk assessment?
Comments: Comments:

Activity No. Activity No.

All 1 2 3 4 5 6 7 8 9 All 1 2 3 4 5 6 7 8 9
 ARE RISK CONTROLS ARE RISK CONTROLS
RISK CONTROLS IN PLACE RISK CONTROLS IN PLACE
Yes No Unsure Yes No Unsure
Is all PPE in accordance with the Australian Dangerous Goods
Other
Code when transporting?
Comments: Comments:

Activity No. Activity No.

All 1 2 3 4 5 6 7 8 9 All 1 2 3 4 5 6 7 8 9

Other Other

Comments: Comments:

Activity No. Activity No.

All 1 2 3 4 5 6 7 8 9 All 1 2 3 4 5 6 7 8 9

ASSESSMENT TEAM:

TEAM LEADER: POSITION: DATE:

CONTROLS
NO OR UNSURE
ABOUT RISK CONTROLS, RAISE ORA AND CALCULATE RELATIVE LEVEL OF RISK FOR MANAGEMENT
IF   BY WHOM: DATE:
RESPONSE