No.

Form : FM-TR-MDYU-06
Revisi : 0
Tgl. Eff : 26 Maret 2019

RISK ASSESSMENT (HIRA) FORM

Department & Exact Location Of The Work Performed: Project / Work Description:
;

Risk Assessment Team (Name/s): Approved By Supervisor / Reporting Officer:

(Name, Date & Signature)

Date Conducted: Next Review Date:

Hazard Identification Risk Evaluation Risk Control

1a. 1b 1c. 1d. 2a. 2b. 2c. 2d. 3a 3b 3c 3d 3e 3f

S/N Work activity Hazard Possible Accident/ Ill Existing Risk Severity Likeli RPN* Additional Risk Severity Likeli RPN* Follow up by Remarks
health to persons, fire or Control hood Control Measures hood (name) & date
property loss
*RPN - Risk Prioritization Number
Risk Assessment Matrix
Risk Prioritisation Number = Severity x Likelihood
Severity Table

Pt Severity level Workplace Safety Workplace Health Environment Fire Damage Downtime Incurred

Fatality, Acute Poisoning, More Than $10 More than 1 year for
Failure of Major Spills to Outside Campus
single or multiple million damages full re-instatement
Bodily Functions
5 Critical
Permanent Body
Injury or Loss of Use Infection with No Infection - outside
Known Cure Campus area
for more than 30 days

Injury requiring 30 days Moderate exposure,

Reversible injury to More Than $1 More than 3 months
of hospitalisation Bodily Functions on Spills to Outside Building million damages for full re-instatement
and/or medical leave prolong recovery
4 Very Serious
Temporary Body Injury Infection with Infection - outside
or Loss of Use for more Known Cure but Building area but within
than 10 days but not extensive treatment Campus
exceeding 30 days

Mild exposure,
Injury requiring 10 days Reversible injury to Spills to Outside More Than $100k More than 1 month for
of hospitalisation Bodily Functions with Laboratory/Room damages full re-instatement
and/or medical leave less than 30 days
recovery
3 Serious

Temporary Body Infection with Infection - outside

Injury or Loss of Use Known Cure but Laboratory area but
for up to 10 days extensive treatment within building

Very Mild exposure,

Injury requiring Reversible injury to Spills to Outside More Than $10k More than 5 days for
maximum of 3 days of Bodily Functions with Workplace but within damages full re-instatement
medical leave only less than 3 days laboratory
recovery
2 Marginal

Temporary Body Infection with Infection - outside

Injury or Loss of Use Known Cure but workplace but within
for 3 days or less treatment needed Laboratory

Very Mild exposure,

Reversible injury to
First aid treatment only Bodily Functions with Spills within Workplace Less than $5k No significant
only damages downtime
less than 3 days
recovery
1 Negligible

No Infection or infection
No or superficial injury No Exposure with no effects within
workplace

Likelihood Table
Pt Likelihood level Likelihood of Occurrence / Exposure Criteria

5 Frequent Likely to occur many times per year

4 Moderate Likely to occur once per year
3 Occasional Might occur once in three years
2 Remote Might occur once in five years
1 Unlikely Might occur once in ten years
Risk level Determination - 5 x 5 Matrix

SEVERITY
Critical Very Serious Serious Marginal Negligible
(5) (4) (3) (2) (1)

Frequent 25 20 15 10 5
(5) Operation not Operation not High priority Review at Risk acceptable
permissible permissible appropriate time

Moderate 20 16 12 8 4
(4) Operation not Operation not High priority Review at Risk acceptable
permissible permissible appropriate time
LIKELIHOOD

Occasional 15 12 9 6 3
Review at appropriate
(3) High priority High priority time Risk acceptable Risk acceptable

Remote 10 8 6 4 2
Review at Review at
(2) appropriate time appropriate time Risk acceptable Risk acceptable Risk acceptable

Unlikely 5 4 3 2 1
(1) Risk acceptable Risk acceptable Risk acceptable Risk acceptable Risk acceptable

Review the risk assessment records every year or whenever there are changes in processes, work activities or upon
any incident occurrence, whichever is earlier.

Action Table
Colour Score Risks Action

Operation not Permissible

16 - 25 High
Stop operation & review controls. If necessary abort
experimentation.

High priority remedial action

12 - 15 Warning Proceed with extreme caution with PI present at all times.

Implement additional (secondary) controls immediately. Review
within 7 days. Emergency control measures shall be in place.

Take remedial action at appropriate time

8 -10 Medium
Proceed with care. Additional control is advised. Review shall be
implemented within 30 days.

Risk acceptable: Residual risk

If possible, risk reduction should be further considered,

1-6 Warning particularly severity.

There are no imminent dangers. Frequent review shall be in place

especially changes in procedures, materials or environment.
Instructions for using the Risk Assessment form
Header Fill up all sections in the header of the RA form.
Note 1: Discuss with your supervisor/reporting officer on the
next review date for the RA. Normally the next review date is up to one year
ahead. The RA is
also reviewed:
(1) When there are changes in work processes/activities
(2) After any accidents/incidents
Note 2: Check your Division rules about
team or individual submission for RA

Column 1b Describe the work activity to be carried out.

Note: Please do not fill in names of machines/equipment to be
used. Therefore, a computer is not an activity, but
working on a computer is
Column 1c Identify hazard(s) associated with the activity to be carried out.
Examples of hazards include chemical, biological, electrical,
mechanical, physical, ergonomics, psychosocial, slip & fall etc.

Column 1d Identify possible accidents/ill health associated with each identified hazard.
Examples of possible accidents/ill health include fires, explosions,
cuts, burns, frost bites, fractures etc.

Column 2a Indicate risk control measures that are already in place to eliminate or minimise risks.
Methods to control risks may be analysed according to the Hierarchy of
Controls: Elimination, Substitution, Engineering Controls, Administrative Controls and
Personal Protective Equipment (PPE). Elimination of the hazard should
take first priority while PPE should be the last line of defence.
Elimination

Example: Use water based solvents instead of organic based solvents

Substitution
Example: Use a less toxic solvent

Engineering Controls
Example: Use of fume cupboard or gloves boxes
Administrative Controls
Example: Work
instructions. Good laboratory practices. Training on proper use of chemicals
PPE
Example: Use of safety eyewear plus
respiratory protection, use of gloves

Column 2b S=Severity
Severity is the degree or extent of injury or harm caused by the
hazards, or as a result of an accident. Choose the most likely severity from a value
between 1 and 5, rather than the most extreme. Refer to the Risk Matrix
tab for the severity table
Column 2c L=Likelihood
Likelihood of occurance of an accident, incident or ill health is defined as
the probability that the said accident, incident or ill health will happen. Choose
the likelihood from a value between 1 and 5. Consider the records of such events
happening in the past when deciding on the likelihood. Refer
to the Risk Matrix tab for the likelihood table

Column 2d RPN=Risk Prioritisation Number

RPN=Severity X Likelihood
All RPNs should not be more than 6

Column 3a Additional risk control measures are required when the RPN indicated in column
2d exceeds 6. If the RPN is 6 or less, enter "NA" in the column

Column 3b S=Severity
S may reduce upon introduction of additional control measures

Column 3c L=Likelihood
L may reduce upon introduction of additional
control measures

Column 3d RPN=Risk Prioritisation Number

RPN will reduce upon introduction of additional control
measures

Column 3e Enter the name of the person appointed to oversee the implementation of the additional
control measures. Enter the follow-up date.

Column 3f Enter any remarks

 RISK ASSESSMENT FORM
School / Department & Exact Location Of The Work Performed: Project / Work Description: Working with Femtosecond Laser Systems
(Example: SPMS -PAP - Lab A)

Risk Assessment Team (Name/s): Johnny (Team Leader), Alice, Roland, Kenny Approved By Supervisor / Reporting Officer:
(Name, Date & Signature)
Prof Tan (Project Supervisor), 16th March 2012
Date Conducted: 11th March 2012 Next Review Date: 10th March 2013

Hazard Identification Risk Evaluation Risk Control

1a. 1b 1c. 1d. 2a. 2b. 2c. 2d. 3a 3b 3c 3d 3e 3f

S/N Work activity Hazard Possible Accident/ Existing Risk Control Severity Likelihood RPN* Additional Risk Severity Likelihood RPN* Follow up by Remarks
Ill health to Control Measures (name) &
persons, fire or date
property loss

1 Operation of Femtosecond Physical Hazard Severe Eye Injuries Beam blocks and beam 3 2 6 NA NA NA NA NA NA
Laser Systems dumps used to blocked
off laser beams.
Only authorised users
are allowed to operate
the system.
Users are equipped with
laser goggles

Electrical Hazard Electrocution due Warning signs are 4 3 12 Regular servicing 4 1 4 (Johnny) 13th NA
to high voltage displayed beside system and maintenance March 2012
to warn users of high of laser system by
voltage vendor
Only authorised
users are allow to
operate the
system
*RPN - Risk Prioritization Number
 RISK ASSESSMENT FORM
School / Department & Exact Location Of The Work Performed: Project / Work Description: Chemical works
(Example: SPMS -CBC - Lab K)

Risk Assessment Team (Name/s): Benny Approved By Supervisor / Reporting Officer:

(Name, Date & Signature)
Prof Xiao (Project Supervisor), 16th March 2012
Date Conducted: 11th March 2012 Next Review Date: 10th March 2013

Hazard Identification Risk Evaluation Risk Control

1a. 1b 1c. 1d. 2a. 2b. 2c. 2d. 3a 3b 3c 3d 3e 3f

S/N Work activity Hazard Possible Accident/ Existing Risk Severity Likelihood RPN* Additional Severity Likelihood RPN* Follow up Remarks
Ill health to Control Risk Control by (name) &
persons, fire or Measures date
property loss

1 Weighing chemicals Irritant Irritation when Handle under 1 3 3 NA NA NA NA NA NA

for the synthesis work Chemicals come in contact fumehood.
with skin and eyes Put on required
PPE - safety
glasses, lab coat,
long pants,
gloves, covered
shoes.

2 Prepare glassware Glass Cuts on skin/eye Inspect glassware 3 3 9 Install 3 1 3 (Benny) NA

and add chemical breakage due due to flying before use. pressure Ongoing
to particles Put on required control /
into chemical overpressure PPE - safety relief valves
reactor (chemical glasses, lab coat,
reaction) long pants, Supervisor to
gloves, covered brief group to
shoes. pull down
fumehood
sash
*RPN - Risk Prioritization Number
 RISK ASSESSMENT FORM
School / Department & Exact Location Of The Work Performed: Project / Work Description: General Office Activities
(Example: Office)

Risk Assessment Team (Name/s): Joey Approved By Supervisor / Reporting Officer:

(Name, Date & Signature)
Mr Lim (Manager), 16th March 2012
Date Conducted: 11th March 2012 Next Review Date: 10th March 2013

Hazard Identification Risk Evaluation Risk Control

1a. 1b 1c. 1d. 2a. 2b. 2c. 2d. 3a 3b 3c 3d 3e 3f

S/N Work activity Hazard Possible Existing Risk Severity Likelihood RPN* Additional Severity Likelihood RPN* Follow up by Remarks
Accident/ Ill Control Risk Control (name) & date
health to Measures
persons, fire or
property loss
1 Sorting of Contact with Cuts and Handle files and 1 4 4 Provide finger 1 3 3 Office Staff NA
documents / Use of sharp edges lacerations to documents with cots to staff to (April 2012)
paper (from paper hand and fingers care, avoiding lift paper
edges and bent fingers running
plaster dividers along the edge of
papers.
Discard bend
plastic folders.

Punching holes for Strike by moving Fingers may get Proper usage of 1 3 3 NA NA NA NA NA NA
document to be parts or caught injured (crush) hole punch
between moving during punching Do not overload
filed parts paper for
punching
Maintenance of
hole puncher
 Ergonomic Muscular starins Staff to adopt 3 1 3 NA NA NA NA NA NA
hazard (repetive good ergonomice
similar action) practice e.g. table
height. Job
rotations; avoid
prolong repetitive
punching
operation.
Brief staff on
proper usage of
hole punch.

*RPN - Risk Prioritization Number