Integrated Risk Management
Research Risk Assessment Form
Document Type:
Control Number:
File Code:
Last Update:
Form
UIRM_FM_009
UIRM-007
March 2017
The risk assessment form is designed to lead the principal investigator, faculty advisor or project supervisor with the objective of
predetermining the necessary control measures prior to the start of work or purchase of equipment.
The principal investigator, faculty advisor or project supervisor should complete the form, and have the department head of the
department review the form. There may be resource requirements associated with your research/project that would require some
commitment from either you and/or your department.
Integrated Risk Management (IRM) is available throughout the risk assessment process. Contact the Environmental Health and Safety
Officer at ext 7086 if you have any questions or email at [email protected]
Process for Research Risk Assessment Form
1. Reviewed and filled out by the principal investigator/faculty advisor/project supervisor and then signed off
2. Reviewed and either sent back to the Supervisor for revisions/additions and/or signed off by the department head
as complete.
3. The original of the COMPLETED Research Risk Assessment Form must be sent to Integrated Risk Management
(IRM)
4. A copy kept within the department
If you feel that the Research Risk Assessment Form hasn't adequately addressed your research / project, please provide any additional
information that would help to expedite the Assessment.
A. Contact Information
PLEASE TYPE OR PRINT CLEARLY
Name:
Dept:
Position:
Email:
Mailing
Address:
Principal
Investigator
Project
Supervisor
Phone
Extension:
Faculty
Advisor
Other
List of people working on project and their affiliation (faculty, staff, undergraduate or graduate student, full time or
part-time, contract or external to Ryerson). Provide attachment if space is insufficient.
Name
Affiliation
B. Project Type
Research
Student Thesis
New Curriculum
Planning
New Equipment
Renovation/Constru
ction
Other (specify)
Process
Change
International Travel
Special Event
Estimated Start
Date:
Project Location (Bldg
& Rm No.
Project Description:
Funded:
No
Yes
ORS Application #: ___________________________________
ORS Officer #:
________________________________________
Faculty of Primary Appointment:
____________________________________
C. Hazards Inventory & Risk Level
Please review all categories and check ALL applicable equipment/agents or activities and estimated risk level for
each category. See Explanatory Notes for Supplementary Information on Risk Analysis Tables. For projects with
several hazardous agents, they may be listed below with individual risk level assessments.
The Supplementary information can be found here:
http://www.ryerson.ca/content/dam/irm/pdfs/Risk%20Assessment%20Form.pdf
EXAMPLE:
Likelihood of an event (Table 1) = should occur at some time LIKELY
Consequence (Table 2) = First aid treatment, on-site release immediately contained, medium financial loss MINOR
Risk (Table 3) = Significant
Agents
IDENTIFY the RISK LEVEL as High / Significant /
Moderate / Low
Biological Agent (e.g., cell cultures, virus, bacteria)
Chemical including all WHMIS classes, cryogenics, etc.
Emission (e.g. dust, odour, heat, particulates, hazardous waste, etc.)
Excessive noise (> 85 dBA)
Excessive vibration
Radioactive Agent (including sealed sources in equipment)
Temperature extremes (< 4oC or > 35 oC)
Other (please list):
H
S
M
L
H
S
M
L
Equipment Inventory
IDENTIFY the RISK LEVEL as High / Significant /
Moderate / Low
Autoclave
Centrifuge
Cutting, puncture or crushing devices
Equipment with exposed moving parts
Excessive weight/floor loading (>80 pounds per ft2)
Laser (Provide Class Number: ________________________________________)
Lifting Device (e.g. crane)
Pressure vessels (e.g. gas cylinders, vacuum, boilers)
Rigging Device
Sharps
X-ray equipment
Other (please describe):
Activities
IDENTIFY the RISK LEVEL as High /
Significant / Moderate / Low
Confined or restricted space
Elevated height (> 3 metres off ground)
Working Alone or in Isolation
Off campus activities
Travelling outside Canada
Other (please describe):
H
S
M
L
HAZARDOUS MATERIALS INVENTORY (i.e., specific chemical, radioactive and/or biohazardous agent(s)].
Please specify concentrations, estimated amounts, activity (for radioactive materials). Provide attachment if space is
insufficient.
Agent
Amount
Concentration
MSDS
Available
YES
NO
Can the hazardous material be eliminated or substituted to a material less hazardous?
No
Yes
List Substitute:
D. Hazard Control Program
Identify hazard control programs and procedures that would be applicable and additional requirements for specific
project
(refer to Appendix B). Provide attachment if space is insufficient. Item with asterisk * indicates a separate
application for an internal permit/certificate is required.
D 1. Agents
*Biological Agent (e.g., cell cultures, virus, bacteria)
Chemical including all WHMIS classes, cryogenics,
etc.
Emission (e.g. dust, odour, heat, particulates,
hazardous waste, etc.)
Excessive noise (> 85 dBA)
Excessive vibration
*Radioactive Agent (including sealed sources in
equipment)
Temperature extremes (< 4oC or > 35 oC)
D 2. Equipment Inventory
Autoclave
Centrifuge
Cutting, puncture or crushing devices
Equipment with exposed moving parts
Excessive weight/floor loading (>80 pounds per ft2)
*Laser
Program
Application for Biosafety Certificate
WHMIS Program
Ventilation & Certificate of Approval (Air)
Certificate of Approval (Noise)
Radiation Safety Program
Program
Machine Safety Guideline
Laser Safety Program
Lifting Device (e.g. crane)
Pressure vessels (e.g. gas cylinders, vacuum, boilers)
Rigging Device
Sharps
X-ray equipment
Compressed Gas Cylinder Guideline
X-Ray Safety Program
D 2 B Equipment Information
Machine guard for equipment (to prevent contact and
entanglements)
Machine appropriate for area of use (explosion-proof, etc.)
YES
NO
NA
Noise contributions been considered for work area
Vibration contributions been considered for work area
Have ventilation requirements for equipment been
considered
Preventative maintenance arrangements for equipment
Sufficient space for safety clearances around equipment
Regular testing requirements (e.g., annual certification) in
place
Does electrical equipment meet CSA/Hydro standards?
D.3 Activities
Confined or restricted space
Elevated height (> 3 metres off ground)
Working Alone or in Isolation
Off campus activities
Travelling outside Canada
D.4 Standard Operating Procedures (SOPs)
Developed for project
Yes
Have project participants reviewed
the SOPs?
Yes
If no, date
completed by:
Program
Travel Risk Assessment Form
No
No
D.5 Control Specifics
Describe control specifics to reduce and minimize risk level of specific hazard. Provide attachment if space is
insufficient.
D. 6 Personal Protective Equipment (PPE) required for the project
Eye/Face
Foot
Head Protection
Protection
Protection
Hand/Skin
Respiratory
Fall
Protection
Protection
Protection
Other
(specify):
D.7 Ventilation Requirements for Hazards and/or Equipment
Hearing Protection
Temperature (head or cold)
Describe local exhaust or general ventilation requirements including type of equipment and location. (required to
minimize exposure to airborne materials including, odour control, heat, dust, chemical, biohazards, radioactive and
waste products)
D.8 List Permits / Special Licensing or Registration requirements used for this project
Air Emissions (C of A -- Air)
Biosafety
Biosafety Cabinets
Crane lifting capacity (annual
Fork Lift
Hydro Inspection
certification)
Radioactive Material
Laser
X-ray Equipment
Hazardous Waste Removal
(describe):
Othe
r:
Have application for permits been
submitted?
State estimated date of
application:
Ye
s
No
D.9 Storage & Disposal of Hazardous Materials
Agent/Equipment temperature
sensitive?
State storage requirements for
hazardous material:
State storage requirements for waste
materials:
State disposal procedures for
hazardous materials:
No
Yes
State Temperature
Requirements:
D.10 Medical Surveillance required for the project
Biological Agents
(immunization)
Eye examination (laser program)
Designated Substances
monitoring
Othe
r:
Travel immunization
D.11 Hazard Communication
Do all of the chemicals being used for this project have up to date (< 3 years old) Material Safety Data Sheets sheets
available?
Yes
No
Where will the MSDS’s
be located?
Have all project participants reviewed
the MSDS’s?
If no, state date
completed by:
Yes
Name
No
Training Requirement
Date Completed By
D.13 Emergency Protocols and Equipment
Emergency procedures (spill, fire, injury etc) posted
at work location?
Procedures reviewed with all staff/students?
If no, date completed
by:
Yes
Yes
No
No
List available emergency equipment
Eyewash
Shower
First Aid Kit
Fire
Extinguisher
Spill Control
Other:
D.14 Access Considerations into Work Area
General Entry/Exit (NO SPECIAL
PRECAUTIONS)
Yes
No
N/A
SPECIAL ENTRY PRECAUTIONS
into work area
Yes
No
N/A
IF YES, STATE WHY precautions are required:
NA
IF YES, are warning visual indicators (eg. signs, alarms, lights, etc.) posted
prior to entering the work area?
Is ACCESS AUTHORIZED for the following personnel:
Security &
Emergency Services
Campus
Facilities &
Sustainability
Yes
No
NA
Restrictio
ns
Yes
No
NA
Restrictio
ns
Caretaking
Yes
No
NA
Trades
Yes
No
NA
IRM
Yes
No
NA
Dept Safety
Officer
Yes
No
NA
Other
Yes
No
NA
Other
Yes
No
NA
Notification of affected
departments
Security &
Emergency
Services
IRM
Campus
Planning
Campus
Facilities &
Sustainability
Caretaking
Other
Required
Restrictio
ns
Restrictio
ns
Restrictio
ns
Restrictio
ns
Restrictio
ns
Restrictio
ns
Not Required
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
Yes
No
No
N/A
N/A
Yes
No
N/A
E. Supplementary Project Information
E.1 Utilities required for the project
Natural Gas
Propane
Vacuum
Natural gas
Hydro/Electri
Steam
cal
Compressed Air
Water
Othe
r:
Are the utilities present in proposed location
sufficient for project?
Yes
No
If no, state additional
requirements:
E.2 Equipment Serviced by these Utilities
Autoclave
Freezer
Biological Safety
Centrifuge
Cabinet
X-ray equipment
Incubator
Fume hood
Fridge
Laser
Vacuum
Othe
r:
Othe
r:
E.3 Services of departments required for completion of project (check all that apply)
ORS
Security
Campus Facilities & Sustainability
DEHSS
CCS
Receiving
Othe
r:
Othe
r:
E.4 Affect of project on other Ryerson departments
Department
Affected
Students
Faculty
Staff
Othe
r:
Description of Impact
F. Principal Investigator /Project Supervisor Confirmation
I am aware of all the potential hazards and have taken all reasonable precautions
necessary to control the hazards related to this proposed activity. I have orientated my
staff on these hazards and necessary control measures, and ensured their competency to
work in a healthy and safe manner. I have obtained or in the process of obtaining the
necessary licences, and permits and have been given the necessary training. I am
familiar with the contents of applicable University health and safety policies and
programs.
Signature:
Date:
Department:
G. Dean/Director/Chair Confirmation
I am satisfied the Principal Investigator/Project Supervisor is aware of, and is
competent to manage all procedures, hazards and safety measures associated with the
project.
Signature:
Date:
RETURN Fully Completed Form to:
Department of Integrated Risk Management (IRM)
Jorgensen Hall 11th floor - 350 Victoria Street
FOR IRM USE ONLY
DISTRIBUTION
IRM
ORS (FUNDED RESEARCH)
Date Received:
Reviewed By EHS Officer
Comments:
Date:
Reviewed By Rad/Bio/Chem Safety Officer
Comments:
Date:
CAMPUS PLANNING & FACITLTIES