HFORM12: COSHH Assessment Form¶
Form Reference: HFORM12 Version: 1.0 Classification: CRGI Information Form Owner: Sean Ashton, Operations Manager Purpose: Document chemical hazard assessment per COSHH Regulations 2002 and HPOL15. Identify substances, classify hazards, assess exposure risk, and define control measures to eliminate or reduce risk to acceptable levels.
Document Control¶
| Version | Date | Author | Changes |
|---|---|---|---|
| 1.0 | 10/03/2026 | Sean Ashton | Initial creation |
1. Assessment Details¶
| Field | Details |
|---|---|
| Assessment Reference | COSHH-____-______ |
| Assessment Date | ________________ |
| Assessor Name & Competency | ________________ |
| Location/Workplace | ________________ |
| Assessment Type | ☐ New substance ☐ Periodic review ☐ Incident investigation ☐ Change of use |
| Next Review Date | ________________ |
| Approval Authority | ________________ |
2. Substance Details¶
| Field | Details |
|---|---|
| Product Trade Name | ________________ |
| Manufacturer/Supplier | ________________ |
| Chemical/Generic Name | ________________ |
| Chemical Composition (main constituents) | ________________ |
| CAS Number (if known) | ________________ |
| Concentration/Purity | ________________ |
| Safety Data Sheet (SDS) Available | ☐ Yes ☐ No |
| SDS Reference/Version | ________________ |
| Quantity Held | ________________ |
| Storage Location | ________________ |
Substance Information Source:
☐ SDS from supplier ☐ ECHA database ☐ Manufacturer website ☐ Workplace records ☐ Other: ________
3. Hazard Classification (GHS/REACH)¶
GHS Pictograms & Hazard Categories¶
Select all hazards that apply:
☐ Flammable – Easily ignitable or combustible ☐ Oxidising – May intensify fire ☐ Corrosive – Causes severe burns/damage to tissue ☐ Acute Toxicity – Harmful/poisonous if ingested, inhaled, or absorbed ☐ Chronic Health Hazard – May cause long-term health effects ☐ Environmental Hazard – Harmful to aquatic life/ozone layer ☐ Serious Health Hazard – May cause respiratory sensitisation or allergic response ☐ Gas Under Pressure – Compressed/liquefied gas ☐ Explosive – May explode if ignited or shocked
Hazard Statements (H-codes)¶
Physical hazards (if applicable):
Health hazards (if applicable):
Environmental hazards (if applicable):
Occupational Exposure Limits (OEL) / Workplace Exposure Limits (WEL)¶
| Hazardous Component | OEL/WEL | Units | Type | Status |
|---|---|---|---|---|
| ________________ | ____ | ☐ mg/m³ ☐ ppm |
☐ 8-hr TWA ☐ Short-term ☐ STEL |
☐ Known ☐ Not set |
| ________________ | ____ | ☐ mg/m³ ☐ ppm |
☐ 8-hr TWA ☐ Short-term ☐ STEL |
☐ Known ☐ Not set |
HSE EH40 Reference: ________________
4. Usage Details¶
| Field | Details |
|---|---|
| Typical quantity used per shift | ____ (units: ______) |
| Frequency of use | ☐ Daily ☐ Weekly ☐ Monthly ☐ Occasional ☐ One-off |
| Duration of use per session | ____ minutes/hours |
| Daily/weekly exposure pattern | ________________ |
| Method/Process of use | ☐ Manual application ☐ Spraying ☐ Mixing ☐ Cleaning ☐ Maintenance ☐ Other: ________ |
| Specific application details | ________________ |
| Location/workplace area | ________________ |
| Time spent in area during use | ____ hours per shift |
5. Persons at Risk¶
Identify all persons who may be exposed:
☐ Users/Operators – Direct contact with substance ☐ Nearby Workers – In vicinity but not directly using ☐ Supervisors/Managers – Overseeing process ☐ Maintenance/Cleaning Staff – Handling containers/spills ☐ Visitors/Contractors – Potential incidental exposure ☐ Vulnerable Persons – Pregnant workers, new/young workers, those with health conditions
Total number of persons potentially exposed: ____
Vulnerable groups identified: ☐ Yes
☐ No
If yes, specify: ________________________________________________________________
6. Routes of Exposure¶
Identify how the substance can enter the body:
☐ Inhalation – Breathing in vapours, mist, dust, or gas ☐ Skin Contact – Direct contact with liquid, dust, or contaminated surfaces ☐ Ingestion – Swallowing (accidental via contaminated hands/food) ☐ Eye Contact – Splashing or airborne particles
Likely routes for this substance:
| Route | Likelihood | Consequence | Risk Level |
|---|---|---|---|
| Inhalation | ☐ High ☐ Medium ☐ Low |
☐ Severe ☐ Moderate ☐ Minor |
☐ H ☐ M ☐ L |
| Skin Contact | ☐ High ☐ Medium ☐ Low |
☐ Severe ☐ Moderate ☐ Minor |
☐ H ☐ M ☐ L |
| Ingestion | ☐ High ☐ Medium ☐ Low |
☐ Severe ☐ Moderate ☐ Minor |
☐ H ☐ M ☐ L |
| Eye Contact | ☐ High ☐ Medium ☐ Low |
☐ Severe ☐ Moderate ☐ Minor |
☐ H ☐ M ☐ L |
Most likely route: ________________
7. Existing Control Measures¶
Identify control measures currently in place:
| Control Measure | Implemented | Effective | Comments |
|---|---|---|---|
| ☐ Substitute with safer substance | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
| ☐ Ventilation/LEV system | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
| ☐ Enclosed/contained process | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
| ☐ Safe storage (locked cabinet/segregated) | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
| ☐ Spill kits available | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
| ☐ Waste disposal procedure in place | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
| ☐ Proper labelling (SDS accessible) | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
| ☐ Staff trained (COSHH awareness) | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
| ☐ Personal Protective Equipment (PPE) | ☐ Yes ☐ No |
☐ Y ☐ N | Type: ________ |
| ☐ Monitoring/inspection schedule | ☐ Yes ☐ No |
☐ Y ☐ N | ________________ |
PPE Currently Required:
☐ Safety glasses/goggles ☐ Chemical-resistant gloves ☐ Apron/protective clothing ☐ Respiratory protection (mask/respirator type: __________) ☐ Safety footwear ☐ Other: ______________________________
8. Risk Assessment¶
Risk Rating per HPROC01 (Likelihood × Consequence)¶
Likelihood of exposure (without controls):
☐ High – Frequent, regular contact expected ☐ Medium – Occasional contact possible ☐ Low – Unlikely unless process changes
Consequence of exposure (if it occurs):
☐ Severe – Could cause death, serious illness, or permanent disability ☐ Moderate – Could cause significant injury, illness, or absence ☐ Minor – Could cause discomfort or temporary minor injury
Risk Matrix Scoring:
| Severe | Moderate | Minor | |
|---|---|---|---|
| High | ☐ Critical (16) | ☐ High (12) | ☐ Medium (8) |
| Medium | ☐ High (12) | ☐ Medium (6) | ☐ Low (3) |
| Low | ☐ Medium (6) | ☐ Low (3) | ☐ Low (2) |
Initial Risk Level (before additional controls): ________________
9. Additional Controls Required¶
Are additional control measures needed to reduce risk? ☐ Yes
☐ No
If yes, specify required measures:
| Control Action | Reason | Owner | Target Date | Cost |
|---|---|---|---|---|
| ________________ | ________________ | ________________ | __________ | _____ |
| ________________ | ________________ | ________________ | __________ | _____ |
| ________________ | ________________ | ________________ | __________ | _____ |
Residual Risk (after all controls implemented): ________________
Is residual risk acceptable? ☐ Yes
☐ No
If no, further action required: ________________________________________________________________
10. Emergency Procedures¶
First Aid Measures (per SDS Route 1–4)¶
| Exposure Route | First Aid Measure |
|---|---|
| Inhalation | ☐ Move to fresh air ☐ Seek medical advice if symptoms persist ☐ Apply oxygen ☐ Other: ________________ |
| Skin Contact | ☐ Wash with soap and water ☐ Remove contaminated clothing ☐ Seek medical advice ☐ Other: ________________ |
| Eye Contact | ☐ Rinse immediately with water (15+ mins) ☐ Seek medical advice ☐ Have eye wash bottle available ☐ Other: ________________ |
| Ingestion | ☐ Rinse mouth ☐ Do NOT induce vomiting ☐ Seek medical advice immediately ☐ Other: ________________ |
Spill & Cleanup Procedure¶
| Item | Details |
|---|---|
| Maximum spill volume manageable in-house | ____ (litres/kg) |
| Spillage containment method | ☐ Absorbent mat ☐ Catch tray ☐ Bund ☐ Sand ☐ Other: __________ |
| Cleanup procedure | ☐ Specialist contractor ☐ In-house trained team |
| Specialist disposal required | ☐ Yes ☐ No |
| Waste code | ________________ |
| Emergency contact (spill >max volume) | ________________ |
Fire Fighting Advice¶
Suitable extinguishing agents:
☐ Water spray ☐ Foam ☐ Dry powder ☐ CO₂ ☐ Other: ________________
Unsuitable extinguishing agents: ________________
Special fire precautions: ________________________________________________________________________________
11. Storage & Disposal¶
Storage Requirements¶
| Requirement | Details |
|---|---|
| Storage location | ☐ Locked cabinet ☐ Designated store ☐ Segregated from incompatibles |
| Ambient conditions | ☐ Cool ☐ Dark ☐ Dry ☐ Ventilated ☐ Specific temp: ____ °C |
| Containment | ☐ Original container ☐ Compatible container ☐ Secondary containment |
| Access control | ☐ Locked ☐ Restricted to trained staff ☐ Labelled |
| Max storage quantity | ____ (units: ______) |
| Shelf life/Expiry date | ________________ |
| Inspection frequency | ☐ Daily ☐ Weekly ☐ Monthly |
Waste Disposal¶
| Item | Details |
|---|---|
| Hazardous waste classification | ☐ Yes ☐ No – Waste code: ________ |
| Waste disposal method | ☐ Specialist licensed contractor ☐ Incineration ☐ Landfill ☐ Other: __________ |
| Disposal contractor | ________________ Contact: ________________ |
| Disposal frequency | ☐ Weekly ☐ Monthly ☐ As required |
| Documentation | ☐ Waste transfer notes retained ☐ Duty of care compliance ☐ TFS register |
12. Health Monitoring¶
Health surveillance required: ☐ Yes
☐ No
If yes, specify:
| Monitoring Type | Baseline | Frequency | Action Level | Responsible |
|---|---|---|---|---|
| ☐ Medical examination | ☐ Yes ☐ No |
____ monthly/yearly | ________________ | ________________ |
| ☐ Biological monitoring | ☐ Yes ☐ No |
____ monthly/yearly | ________________ | ________________ |
| ☐ Health questionnaire | ☐ Yes ☐ No |
____ monthly/yearly | ________________ | ________________ |
Occupational health contact: ________________ Tel: ________________
Environmental monitoring required: ☐ Yes
☐ No
If yes, monitoring schedule: ________________________________________________________________
13. Approval & Review¶
Assessment completed by (name & title): ________________ Signature: ________________ Date: __________
Approved by (manager/senior): ________________ Signature: ________________ Date: __________
Review frequency: ☐ Annually
☐ Every 2 years
☐ Following change
☐ As required
Last review date: __________ Next review due: __________________
Changes since last review: ☐ Yes
☐ No – Details: ________________________________________________________________
RETENTION: Duration of substance use + 40 years (if exposure record required) STORAGE: HREG16 COSHH Register + Secure SharePoint – /HSQEMS/COSHH/ ACCESS: Operations Manager, Staff using substance, Occupational Health, Health & Safety CLASSIFICATION: CRGI Information
Related Documents: HPOL15, HREG16, HPROC01, SDS
END OF FORM