| A | B | C | D | E | F | G | H | I | J | K | |
|---|---|---|---|---|---|---|---|---|---|---|---|
1 | University of the Philippines Diliman College of Engineering Department of Chemical Engineering | ||||||||||
2 | |||||||||||
3 | Experiment-Based Risk Assessment Form | ||||||||||
4 | |||||||||||
5 | Name of Department | Room Number/Location of Laboratory | |||||||||
6 | |||||||||||
7 | Laboratory Affliation | Name of Adviser | |||||||||
8 | |||||||||||
9 | Name of Researcher/Technician | Name of Activity/Experiment | |||||||||
10 | |||||||||||
11 | |||||||||||
12 | |||||||||||
13 | 1. Hazard Identification | 3. Risk Control | |||||||||
14 | No | Detailed steps to be performed in experiment (inclusive of materials and equipment to be used) | Hazards from materials or equipment | Possible Accident / Exposure / Injury | Existing Risk Control (Safety Measures) | Severity | Likelihood (Probability) | Risk Level | Additional Risk Control | Person Responsible | Performed at date |
15 | 1 | 0 | |||||||||
16 | 2 | 0 | |||||||||
17 | 3 | 0 | |||||||||
18 | 0 | ||||||||||
19 | 0 | ||||||||||
20 | 0 | ||||||||||
21 | 0 | ||||||||||
22 | 0 | ||||||||||
23 | 0 | ||||||||||
24 | 0 | ||||||||||
25 | |||||||||||
26 | Conducted By | (Full Name and Signature) | Approved By | ||||||||
27 | date | ||||||||||
28 | (Full Name and Signature) | Name | Dr. Raven P. Lingating, HSE Officer | ||||||||
29 | date | ||||||||||
30 | (Full Name and Signature) | Signature | |||||||||
31 | date | ||||||||||
32 | Endorsed By | (Adviser's Name and Signature) | Approval date | ||||||||
33 | date | ||||||||||
34 | |||||||||||