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Lone Working Risk Assessment Form

    Area work being carried out

    Person completing risk assessment

    Date Prepared

    Review Date

    Assessment Form

    You can add more hazards by checking the 'Add Another Hazard' box at the bottom of the form

    Hazard ref: 1

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:

    Severity:

    Risk Level:

    Further Action Required?:


    Residual Risk:
    Likelihood:

    Severity:

    Risk Level:

    Due (date):

    + Add: Add another Hazard

    Hazard ref: 2

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:

    Severity:

    Risk Level:

    Further Action Required?:

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    Risk Level:

    Due (date):

    + Add: Add another Hazard

    Hazard ref: 3

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
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    Severity:

    Risk Level:

    Further Action Required?:


    Residual Risk:
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    Due (date):

    + Add: Add another Hazard

    Hazard ref: 4

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
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    Further Action Required?:

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    Due (date):

    + Add: Add another Hazard

    Hazard ref: 5

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
    Severity:
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    Further Action Required?:

    Residual Risk:
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    Due (date):

    + Add: Add another Hazard

    Hazard ref: 6

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
    Severity:
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    Further Action Required?:

    Residual Risk:
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    Due (date):

    + Add: Add another Hazard

    Hazard ref: 7

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
    Severity:
    Risk Level:

    Further Action Required?:

    Residual Risk:
    Likelihood:
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    Due (date):

    + Add: Add another Hazard

    Hazard ref: 8

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
    Severity:
    Risk Level:

    Further Action Required?:

    Residual Risk:
    Likelihood:
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    Due (date):

    + Add: Add another Hazard

    Hazard ref: 9

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
    Severity:
    Risk Level:

    Further Action Required?:

    Residual Risk:
    Likelihood:
    Severity:
    Risk Level:

    Due (date):

    + Add: Add another Hazard

    Hazard ref: 10

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
    Severity:
    Risk Level:

    Further Action Required?:

    Residual Risk:
    Likelihood:
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    Due (date):

    + Add: Add another Hazard

    Hazard ref: 11

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
    Severity:
    Risk Level:

    Further Action Required?:

    Residual Risk:
    Likelihood:
    Severity:
    Risk Level:

    Due (date):

    + Add: Add another Hazard

    Hazard ref: 12

    Hazard:

    Persons at risk:

    Control measures:

    Initial Risk:
    Likelihood:
    Severity:
    Risk Level:

    Further Action Required?:

    Residual Risk:
    Likelihood:
    Severity:
    Risk Level:

    Due (date):

    You cannot add any more items, please fill in another form

    Name:

    Date:

    Signature: