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COSHH Assessment Form

|This assessment only addresses the risk of harm to health from the substances listed. Additional risk assessments may be required to control the risk from|

|other hazards associated with this work/the procedures used. |

|Assessor (print) (1) |Employer/Supervisor (2) |

|Assessment Date (3) |Dates reviewed(4) |

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|HAZARDS IDENTIFIED |

|*If the substance has a R45 or R49 risk phrase or a H350 or H350i hazard statement, it must also be registered on your personal carcinogen return (at |

|Occupational Health) where exposure is not adequately controlled. |

|Substance(5) |Hazardous Properties(6) |Quantity(7) |

|(Name of Chemical, etc. as appropriate); NB. |(Provide details of how the substance could cause |(Indicate how much of the substance |

| |harm, e.g. harmful by inhalation, skin contact, |will be used) |

| |flammable, carcinogen, allergen, etc) | |

| | | |

|Additional information(8) |

|Workplace Exposure Limits: |

|R-phrases: |

|S-phrases: |

|H and P statements: |

|Emergency Procedures(9) |

|Eye contact: |

|Inhalation: |

|Skin contact |

|Ingestion: |

|Spill procedure: |

|What will the chemical be used for? (insert title of experiment or experimental procedure) Who may be exposed? (10) |

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|METHODS OF PREVENTION OR CONTROL OF EXPOSURE |

|(select all that apply by circling/ticking/highlighting the appropriate statement) |

|1. Engineering controls required(11) |2. Access control(12) |

|total containment |restricted to competent personnel |

|fume cupboard |special containment facility (give specific area): |

|local exhaust ventilation | |

|blast screen | |

|3. Special procedures(13) |4. Approved PPE(14) ( Note: PPE is to be used as the ‘last resort’ when |

|Standard Operating Procedure (SOP) required ( |controlling exposure) |

|Code of practice, local rules, etc ( |gloves etc (specify type) |

| |eye protection (specify type) |

| |laboratory coat/overalls (specify type) |

| |other PPE (specify) |

|Disposal Procedures(15) (Give details of waste disposal procedure to be used) |

|Are chemicals with risk phrases R50-R59 or hazard statements H400 – H413 (environmental |

|hazards) involved? Yes / No |

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|TRAINING REQUIREMENTS(16) |

|(List any specialised training requirements before work can begin) |

|HANDLING AND STORAGE REQUIREMENTS(17) |

|(Note any special requirements e.g. ventilation, chemical incompatibility, flash point, etc) |

|ASSESSMENT OF RISK USING CONTROLS DETAILED ABOVE(18) |

|(Are the hazards/risks suitably controlled, using the control measures detailed above? If not, state the further actions required, e.g. Requirement for a |

|standard operating procedure (SOP), etc). |

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|Authorisation by Employer/Supervisor 19 |

|I confirm that I have considered and understand the chemical to be used and the associated hazards. I am satisfied that all of the hazards have been |

|identified and that the control measures to be followed will reduce the risks to as low a level as reasonably practicable. |

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|Print name: Signed: |

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|Date: |

Declaration by Employer/Supervisor (20)

I confirm that I have read this COSHH Assessment and that I understand the hazards and risks involved and will follow all of the safety procedures stated.

Declaration by employee201

|Name (please print) |Signed |PI countersignature |date |

| | | | |

| | | | |

I confirm that the employee who has signed below is competent to undertake the work. My counter-signature indicates that I am happy for the work to proceed.

Guidance notes for COSHH assessment form

This form must be completed for every hazardous chemical used within the company. The form must be signed by the employee and their employer/supervisor before the work starts.

1) Assessor: Insert the name of the person doing this assessment

2) Employer/Supervisor Insert the name of the Employer/Supervisor.

3) Assessment Date: Insert the date that the assessment form is completed. The assessment is valid for a maximum of 1 year. It must be reviewed after 1 year, or if a significant change occurs (change of lab, pregnancy, etc).

4) Dates reviewed: all COSHH assessments must be reviewed annually (as a minimum). The review date should be entered here, and signed by the assessor to confirm that the assessment is still valid.

5) Substance: insert name of the chemical to be used. NB. Biological hazards must not be assessed on this COSHH form.

6) Hazardous properties: insert details of all of the hazardous properties of the chemical – egg. Flammable, explosive, carcinogen, harmful by inhalation, etc).

7) Quantity: insert quantity to be used (mg, g, ml, etc)

8) Additional information: Include details of any additional information, including any workplace exposure limits. Detail fully all R/S phrases and H and P statements (it is not sufficient to simply stat R45, full details are needed).

9) Emergency procedures: provide full details of emergency procedures to be employed following contact with the chemical (skin contact, eye contact, inhalation and ingestion) – such as use of diphoterine, administration of emergency oxygen, etc. Also include details of emergency spill procedures.

10) What will the chemical be used for? Who may be exposed? : Insert title of experiment or experimental procedure that the chemical is to be used in, and detail who may be exposed (individual worker? People in close proximity? Cleaners? Engineers?).

Methods of prevention or control of exposure

Sections 11-14 detail the methods for preventing or controlling exposure to the chemical. The COSHH hierarchy of control measures should be used when determining the methods to be used to prevent/control exposure, with engineering and group control measures being employed in preference to individual measures (such as individual PPE).

11) Engineering controls required: identify the control measures necessary to prevent/control exposure, such as use of a fume cupboard, LEV or blast screen, by circling/ticking/highlighting the appropriate statement(s).

12) Access control: In order to prevent/control exposure, is it necessary to restrict access to competent personnel? Are special containment facilities required? Please circle/tick/highlight the appropriate statement(s).

13) Special procedures: please identify any special procedures necessary to prevent/control exposure. This might include the need for an SOP to be developed, or for local rules to be drawn up. Please circle/tick/highlight the appropriate statement(s).

14) Approved PPE: PPE is to be used as the ‘last resort’ when preventing/ controlling exposure. Please detail the PPE to be used when handling the chemical. Please circle/tick/highlight the appropriate statement(s) and include details of the type of gloves, etc to be used.

15) Disposal procedures: Identify whether the chemical is an environmental hazard; Detail fully how the chemical waste is to be disposed of (down sink, by specialist contractor, etc)

16) Training requirements: detail any specialised training requirements that must be met before the work can begin – eg. Attendance on a gas safety course, etc).

17) Handling and storage requirements: Note any special requirements e.g. ventilation, chemical incompatibility, flash point, etc.

18) Assessment of risk using controls detailed above: Are the hazards/risks suitably controlled, using the control measures detailed above? Provide details; If not controlled, state the further actions required, eg. Requirement for a standard operating procedure (SOP), etc.

19) Authorisation by Employer/Supervisor: the employer/supervisor must sign and date the assessment, to confirm that they have considered and understand the chemical to be used and the associated hazards, and that they are satisfied that all of the hazards have been identified and that the control measures to be followed will reduce the risks to as low a level as reasonably practicable.

20) Declaration by employee: the employee must sign and date the assessment to confirm that they have read the COSHH Assessment, understand the hazards and risks involved and will follow all of the safety procedures stated.

21) Declaration by Employer/Supervisor: the employer/supervisor must sign and date the assessment, to confirm that the researcher is competent to undertake the work.

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