COSHH Assessment Form

1
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)
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)
(Name of Chemical, etc. as appropriate);
NB.
Hazardous Properties
(6)
(Provide details of how the substance
could cause harm, e.g. harmful by
inhalation, skin contact, flammable,
carcinogen, allergen, etc)
Quantity
(7)
(Indicate how much of the
substance will be used)
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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COSHH Assessment Form PDF

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