Form 0920-15XT Att E Risk Assessment

Attachment E

Risk Assessment Measures

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Risk Assessment Measure

For each hazard, please indicate the accident severity you think is associated with the hazard, the probability and accident will occur if that hazard is present, and the overall risk level for that hazard by putting a circle around the option you prefer. Please do not think too long before answering; usually your first inclination is also the best one.

Risk Assessment		Numeric Value of Assessment
	1	2	3	4	5
Accident severity	No injury	Minor injury with no sick leave required	Injury requiring at least 3 days sick leave	Non-fatal major injury	Fatal
	1	2	3	4	5
Accident probability	Very unlikely/infrequent	Fairly unlikely/infrequent	Average Likelihood	Fairly likely/frequent	Very likely/frequent
	1	2	3	4	5
Risk level	Very low	Low	Medium	High	Very high

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).