HSF 003

COSHH Risk Assessment Form

Substance Information
SDS Section Reference / Substance/Material / Trade Name/
Manufacturer
Sections:
1, 2, 3 & 8 / What is the substance to be used for?
(e.g. cleaning floors, pool chemicals)
Please list any Workplace Exposure Limits (WEL) where applicable: / Is the Manufacturer’s Safety Data Sheet (SDS) available? / Yes No
Is the substance:
Flammable/Highly Flammable / / Oxidising / / Irritant/Harmful /
Toxic/Very Toxic / / Corrosive / / Gas Under Pressure /
Dangerous for Environment / / Explosive / / Carcinogen, Mutagen
Respiratory sensitiser
Reproductive toxicity /
Is the substance hazardous to health when:
In contact with skin? Breathed in? Other (specify below)
In contact with eyes? Swallowed?
Use of Substance
How will the substance be used?
(e.g. diluted in water, applied with a brush)
How much is used every week?
(State quantity, give units e.g. litres, kilos etc.) / What is the typical duration of use?
(max hours/week)
Who is exposed to the substance?
(e.g. pupils, service users, employees)
Does the substance present additional risks to certain groups or individuals?
(e.g. young people, expectant mothers)
Control Measures
Can a less hazardous substance be used to do the same job? Yes No
(If you don’t know, contact your supplier)
Section 8 / What controls are required for this substance, refer to hierarchy of control measures)
(e.g. well ventilated areas, not spray/mist form, mechanical ventilation, authorised persons only)
Section 8 / Is any personal protective equipment required when using the substance? (Please state type required)
Eye Protection / / Hand protection (gloves) / / Overalls/Clothing / / Mask/Respirator /
Other (Please specify) /
Section 7 / How should the substance be stored?
(e.g. locked cupboard, away from other substances)
Have persons using this substance been provided with information or training on its use?
Yes No (If No, please include in your remedial action table below.)
Other Precautions and Emergency Procedures
Section 6 / Spillages: How should an accidental release/spillage of this substance be dealt with?
Section 4 / First Aid: What actions should be taken if the substance is:
a) Swallowed? / b) In contact with eyes?
c) In contact with skin? / d) Inhaled
e) Other? (please specify)
Section 5 / Fire Precautions: What actions should be taken in the event of fires involving this substance?
Section 10 / Chemical reactions: Is there any other substance that this substance must not come into contact with?
Sections 6, 13 / Disposal: How should the substance be disposed of (or not disposed of)?
Assessment of Risk
Are all the controls details above currently in place? Yes No
Are hazards to health adequately controlled with all control measures in place? Yes No
If these controls are not in place or additional controls are required, state action to be taken.
Please note – COSHH substances must not be used if adequate measures are not in place.
Remedial actions required / Responsible Person / Target Date
1. 
2. 
3. 
4. 
5. 
6. 
Assessor(s) name: / Assessor(s) signature:
Date Completed: / Review Date:
The line manager should sign below to show that the assessment is a reasonable reflection of the hazards and of the control measures and actions required
Line Managers name: / Line Managers signature: / Date:
Doc. No. / Issue No. / Prepared & Approved by / IMS Approval / Date / Page
HSF 003 / 04 / Corporate H&S Team / IMS Co-ordinator / Feb 2018 / 2