ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
UTMOSHE-P0612-HIR
2
HIRARC FORM
3
4
5
6
Faculty/School/Unit/Laboratory/ Workshop:Conducted by: (Name, Designation, Signature)Signature and Name of Student
7
8
Work Process:Conducted Date:From: Until:
9
Location/Block:
10
Approved by: (Name, Designation, Signature)For office use (Signature of HSEA)Reviewed by: (Name, Designation, Signature)Signature and Name of Supervisor
11
12
Approval Date : For office use (HSEA)Review Date:
13
Next Review Date:
14
1. HAZARD IDENTIFICATION2. RISK ANALYSIS3. RISK CONTROL
15
No.Activities (Routine / Non-Routine)Actual and Potential HazardsWhich can Cause Potential Consequences / Risk EffectsExisting Control MeasuresLikelihood (A)Severity (B)Risk Level (A) x (B)Legal & Other RequirementsAdditional / Recommended Control MeasuresPerson In Charge (Due Date / Status)
16
1Type of hazards
17
18
2Type of hazards
19
20
3Type of hazards
21
22
23
Likelihood (A)Severity (B)
Hierarchy of Control
Risk Level
24
5 - Most Likely (The most likely result of the hazard / event being realized)
5 - Catastrophic (Numerous fatalities, irrecoverable property damage and productivity)1 - Elimination1-4 (Low)
25
4 - Possible (Has a good chance of occurring and is not unusual)
4 - Fatal (Approximately one single fatality major property damage if hazard is realized)2 - Substitution5-12 (Medium)
26
3 - Conceivable (Might be occur at sometime in future)
3 - Serious (Non-fatal injury, permanent disability)3 - Isolation13-25 (High)
27
2 - Remote (Has not been known to occur after many years)
2 - Minor (Disabling but not permanent injury)4 - Engineering Control
28
1 - Inconceivable (Is practically impossible and has never occurred)
1 - Negligible (Minor abrasions, bruises, cuts, first aid type injury)5 - Administration Control
29
6 - Personal Protective Equipment (PPE)
30
31
Legal & Other RequirementsHazard Category
32
L1 - Occupational Safety and Health Act 1994 (Act 514)
Chemical/Kimia
33
L2 -Factories and Machinery Act 1967 (Act 139)Physical/Fizikal
34
L3 - Atomic Energy Licensing Act 1984 (Act 304)
Mechanical/Mekanikal
35
L4 - Biosafety Act 2007 (Act 678)Electrical/Elektrikal
36
L5 - Electricity Supply Act 1990 (Act 447)Biological/Biologikal
37
L6 - Fire Service Act 1988 (Act 341)Ergonomic/Ergonomik
38
L7 - Others Act & Regulation (Specify)Psychological/Psikologikal
39
L8 - NIL (Not In List)
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100