Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 4 38 of 53 8 WORK ALON E RI SK A SSE SS M ENT F O RM Doc u m e n t Identif icat ion F R M 003 P age Nu m b e r 1 of 2 Doc u m e n t C r e ation Dat e Ma rc h 10 2016 Im p le m e n tat ion Dat e Apr il 1 2016 I N STR U C TI ON S C ompl e te the wor kshe e t on pa ge 3 with t he wor k e r f or e a c h si tuation whe r e a wor k e r is wor kin g a lo ne a nd ma y be a t risk of a n inj ur y tha t would pre ve nt hi m he r f rom obtaining he lp 1 I n the t a ble on pa ge 2 a C onsi de r w hich ha z a rds i n c olum ns A a nd B mi g h t appl y a nd sp e c if y the in jur y in column C pa ge 3 b F or c olum n D Use Ta bl e 1 on pa g e 2 to ass e ss t he prob a bil it y o f the a c c id e nt occ ur ring c F or c olum n E Use Ta bl e 2 on pa g e 2 to ass e ss t he li ke li hood that the a c c i de nt would re sult in an inj ur y se rious e nou g h to be disa bli ng d F or c olum n F Use T a bl e 3 on pa g e 2 to ass e ss the likelihood of he lp bein g a v a il a ble to the w ork e r e R a te the re quir e ment f or a c he c k in s y st e m b y mul ti pl y in g the numb e rs in C olum ns D E a nd F Ente r the r e sult in C olum n G 2 Ente r the sc or e fr om C ol umn G a dd a ll in t his colum n int o the F inal Ri sk S c ore be low I n c lude c o mm e nts a nd re c omm e nd a ti ons a s re quire d 3 I f the Ri sk S c ore is Less than 2 00 low C heck in at t he begin nin g and end of the shif t o r task or as of ten as required b y the natu re of the task Between 20 0 and 4 00 m o derate a check in p rocedure m u st be i mple m e nted Greater than 400 hi gh the checks must b e f requent and o ther m it igat ion m ust b e consi dered and i m ple mented RISK S CORES L E VE L S The R isk Assessments wil l dete rmine the r isk of indi vidual tasks R isks a re divi de d int o thre e c a te g o rie s L e ve l 1 Risk Sc or e is gr e a t e r t h a n 40 0 F re qu e nc y of c he c k ins a t l e a st eve r y hour a nd e nd of shi ft L e ve l 2 Risk Sc or e is be t we e n 20 0 a n d 40 0 F re qu e nc y of c he c k ins e ve r y 2 hou rs or more ofte n a s is re quire d b y t he na ture of th e task a n d e nd of shift L e ve l 3 Risk sc or e is l e s s tha n 20 0 F re qu e nc y of c he c k in c he c k in a t the b e g inni ng a nd e nd of the shift or t a sk or a s ofte n a s is re q uire d b y the na ture of th e task