OPERATIONAL RISK ASSESSMENT WORKSHEET

OPERATIONAL RISK ASSESSMENT WORKSHEET

1. MISSION:

5. PREPARED BY:

6. HAZARD:

LIST YOUR POSSIBLE HAZARDS HERE

RANK / LAST NAME/ DUTY POSITION

7. INITIAL RISK LEVEL:

RAC CODE

8.

WHAT ARE YOUR CONTROL FEATURES FOR THE LISTED HAZARD TO THE LEFT

2. DATE BEGIN: END:

3. DATE PREPARED:

Page ______ of ______ 4. DESIGNATOR NUMBER:

9. RESIDUAL RISK LEVEL:

RAC CODE AFTER CONTROLS

10. HOW TO IMPLEMENT:

ANSWER THE ABOVE QUESTION

SIGNATURE

11. HOW TO SUPERVISE:

LIST YOUR SUPERVISORY TOOLS HERE

12. CONTROLS EFFECTIVENESS:

AAR COMMENTS

13. OVERALL RISK LEVEL AFTER CONTROLS ARE IMPLEMENTED: (Check One)

RAC 1 (CRITICAL)

RAC 2 (SERIOUS)

RAC 3 (MODERATE)

RAC 4 (MINOR)

RAC 5 (NEGLIGBLE)

14. RISK DECISION AUTHORITY: RANK / LAST NAME/ DUTY POSITION

MCB Form 5100/12 (12/04) (EF)

PREVIOUS EDITIONS ARE OBSOLETE

SIGNATURE

Designed using Adobe Form Designer 5.0 MCB/ADJ December 2004

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