RISK ANALYSIS FORM

Individuals Name:	Date of Meeting:

Facilitators Name:

Name of Persons Attending	What Role do they have

Situation/Activity Context of the Risk (what would the best case scenario look like? The who, what, where and how?)

Potential Risk Areas – Page 1
Brainstorm potential risks that may occur in the existing or proposed situation/activity. Give a “gut” preliminary feel. What might he or she do that could have negative consequences? What risky situation might arise that we need to avoid or plan an effective response?	Priority

1 - 6
Potential for surprise (what role do chance and unpredictable occurrences play?)

Analyzing the Risk – Page 2

Potential Cause of Risk (from chart on Page 1):

Consider, list and individually rate all potential consequences for:

Self (e.g. physical harm, either deliberate or accidental);

Opportunities (e.g. loss of home situation, employment, recreation/leisure;

Others (e.g. physical harm, relationships);

Property/Environment (include personal belongings, those of others; home, work and public places);

Organization (e.g. reputation, contract, statutory, civil suit).
Potential consequences should this occur:

Current measures to manage this concern:

Consequence, Likelihood Score, Risk Rating:

Analyzing the Risk – Page 2 Continued

Potential Cause of Risk (from chart on Page 1):

Consider, list and individually rate all potential consequences for:

Self (e.g. physical harm, either deliberate or accidental);

Opportunities (e.g. loss of home situation, employment, recreation/leisure;

Others (e.g. physical harm, relationships);

Property/Environment (include personal belongings, those of others; home, work and public places);

Organization (e.g. reputation, contract, statutory, civil suit).
Potential consequences should this occur:

Current measures to manage this concern:

Consequence, Likelihood Score, Risk Rating:

Analyzing the Risk – Page 2 Continued

Potential Cause of Risk (from chart on Page 1):

Consider, list and individually rate all potential consequences for:

Self (e.g. physical harm, either deliberate or accidental);

Opportunities (e.g. loss of home situation, employment, recreation/leisure;

Others (e.g. physical harm, relationships);

Property/Environment (include personal belongings, those of others; home, work and public places);

Organization (e.g. reputation, contract, statutory, civil suit).
Potential consequences should this occur:

Current measures to manage this concern:

Consequence, Likelihood Score, Risk Rating:

Analyzing the Risk – Page 2 Continued

Potential Cause of Risk (from chart on Page 1):

Consider, list and individually rate all potential consequences for:

Self (e.g. physical harm, either deliberate or accidental);

Opportunities (e.g. loss of home situation, employment, recreation/leisure;

Others (e.g. physical harm, relationships);

Property/Environment (include personal belongings, those of others; home, work and public places);

Organization (e.g. reputation, contract, statutory, civil suit).
Potential consequences should this occur:

Current measures to manage this concern:

Consequence, Likelihood Score, Risk Rating:

Analyzing the Risk – Page 2 Continued

Potential Cause of Risk (from chart on Page 1):

Consider, list and individually rate all potential consequences for:

Self (e.g. physical harm, either deliberate or accidental);

Opportunities (e.g. loss of home situation, employment, recreation/leisure;

Others (e.g. physical harm, relationships);

Property/Environment (include personal belongings, those of others; home, work and public places);

Organization (e.g. reputation, contract, statutory, civil suit).
Potential consequences should this occur:

Current measures to manage this concern:

Consequence, Likelihood Score, Risk Rating:

What More Can We Do? – Page 3

Potential Cause of Risk (from chart on Page 1):
Re-list all potential consequences you want to do something more about (at least those rated High or Extreme):

Additional measures to lower Likelihood and/or Consequences:

Consequence, Likelihood Score, Risk Rating:

What More Can We Do? – Page 3 Continued

Potential Cause of Risk (from chart on Page 1):
Re-list all potential consequences you want to do something more about (at least those rated High or Extreme):

Additional measures to lower Likelihood and/or Consequences:

Consequence, Likelihood Score, Risk Rating:

What More Can We Do? – Page 3 Continued

Potential Cause of Risk (from chart on Page 1):
Re-list all potential consequences you want to do something more about (at least those rated High or Extreme):

Additional measures to lower Likelihood and/or Consequences:

Consequence, Likelihood Score, Risk Rating:

What More Can We Do? – Page 3 Continued

Potential Cause of Risk (from chart on Page 1):
Re-list all potential consequences you want to do something more about (at least those rated High or Extreme):

Additional measures to lower Likelihood and/or Consequences:

Consequence, Likelihood Score, Risk Rating:

What More Can We Do? – Page 3 Continued

Potential Cause of Risk (from chart on Page 1):
Re-list all potential consequences you want to do something more about (at least those rated High or Extreme):

Additional measures to lower Likelihood and/or Consequences:

Consequence, Likelihood Score, Risk Rating:

Making a Decision – Page 4

Situation /Activity (Best case scenario from Cover Page):
Benefits

Any Risk in Not Proceeding

Action Plan for Risk Mitigation (New Actions & Changes Only)
What will be done	By Who	By When
Next meeting to be organized / chaired by:

Print Name	Signature

Plan will be followed up (next meeting) on:

Date

14

Risk Assessment – Recorder / Revised July 2011

PDD Vision –

Michener

2011-07-22

GOA