SAMPLE RISK ASSESSMENT FORM

REF ID NO.	SUBMITTED BY	DATE SUBMITTED

RISK TYPE select one

Financial
Legal / Contractual
Reputation / Customer Relations
Resources
Operational
Other:

RISK DESCRIPTION

SOURCE OF RISK

PERSON(S) IMPACTED check all that apply

Customers / Clients
Employees
Contractors
Public
Other:
Other:
Other:

RISK IMPACT select one

IMPACT LEVEL	DESCRIPTION
NOT SIGNIFICANT	Negligible injuries not needing medical treatment
MINOR	Minor injuries causing temporary impairment needing medical treatment
MODERATE	Illness and/or injury requiring hospitalization
MAJOR	Illness and/or injury resulting in permanent impairment
SEVERE	Fatality

RISK PROBABILITY select one

PROBABILITY LEVEL	DESCRIPTION
HIGHLY UNLIKELY	Rare chance of an occurrence
UNLIKELY	Not likely to occur under normal circumstances
POSSIBLE	May occur at some point under normal circumstances
LIKELY	Expected to occur at some point in time
HIGHLY LIKELY	Expected to occur regularly under normal circumstances

RISK SEVERITY MATRIX based on Impact and Probability Levels

IMPACT x PROBABILITY	NOT SIGNIFICANT	MINOR	MODERATE	MAJOR	SEVERE
HIGHLY UNLIKELY	LOW	LOW	LOW / MED	MEDIUM	MEDIUM
UNLIKELY	LOW	LOW / MED	LOW / MED	MEDIUM	MED / HIGH
POSSIBLE	LOW	LOW / MED	MEDIUM	MED / HIGH	MED / HIGH
LIKELY	LOW	LOW / MED	MEDIUM	MED / HIGH	HIGH
HIGHLY LIKELY	LOW / MED	MEDIUM	MED / HIGH	HIGH	HIGH

RISK SEVERITY LEVEL select corresponding Severity Level from matrix above based upon Impact and Probability Levels

SEVERITY LEVEL
LOW
LOW / MED
MEDIUM
MED / HIGH
HIGH

CURRENT CONTROL MEASURES

FURTHER ACTION NEEDED? select one

YES
NO

ACTIONS TO IMPLEMENT if applicable

ACTION	ASSIGNED TO	DUE DATE	STATUS

DATE REVIEWED	APPROVING OFFICIAL NAME & TITLE	SIGNATURE

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