(1) In case of Emergency:	(2) Fire Fighting medium	Choose an item.
The following services are being used:	Electricity	Water	Gases: (specify)	Other:
☐	☐	Click here to enter text.	Click here to enter text.
Action in case of Fire:	Click here to enter text.	Spillage or release measures:	Click here to enter text.
First aid requirements:	Click here to enter text.
This is a chemical risk assessment only and other assessments may be required. All associated assessment forms must be displayed close to the procedure.
(3) Risk Assessment Number/Code:	Click here to enter text.	(4) Name and status of researcher e.g. Phd..	Click here to enter text.	(5) Emergency contact details:	Click here to enter text.
(6) Assessment Date:	Click here to enter a date.	(7) Review/Expiry Date:	Click here to enter a date.	(8) Building and office Number:	Click here to enter text.	(9) Lab Number:	Click here to enter text.	(10) People Affected:	Click here to enter text.
(11) Title of procedure:	Click here to enter text.
(12) Details of procedure and where applicable reaction scheme (Including starting materials, products/by-products and pressure):	(14) Associated Assessments and Ref
Click here to enter text.	General risk assessment for experiment	☐
Equip/Exp overnight running	☐
General lab activities	☐
Ionizing radiation	☐
Non-Ionizing radiation	☐
Laser Safety	☐
Biological/Bio-COSHH	☐
Radiological	☐
(13) Duration, Frequency and Temperature Range:	RA/P&M Sheets/SOP/Other (include ref):
Click here to enter text.	Click here to enter text.
(15) Substances used and produced	(16) Quantity used and handled	(17) Duration of potential exposure	(18) Hazard Symbols	(19) Physical and health hazard statements Highlight primary hazard	(20) Workplace Exposure Limits	(21) Control Measures	(22) Disposal Route	(23) Extremely or Highly Flammable?
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5. Click here to enter text.	Click here to enter text.	Click here to enter text.	Click Here Click Here Click Here Click Here	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	☐
6.Click here to enter text.	Click here to enter text.	Click here to enter text.	Click Here Click Here Click Here Click Here	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	☐
7. Click here to enter text.	Click here to enter text.	Click here to enter text.	Click Here Click Here Click Here Click Here	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	☐
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(24) Operation is (mark as appropriate): Open ☐ Closed ☐ Pressurised ☐ Pressure relief system ☐ other ☐ Please specify here.
(25) Are you carrying out an activity/chemical reaction that is at risk of a thermal runaway or explosion? Choose an item. If yes, what additional controls are required? Click here to enter text.
(26) Will the activity involve handling or storage of pyrophoric or unstable substances such as peroxide? Choose an item. If yes, what additional controls are required? Click here to enter text.
(27) Will flammable vapours, solid particles, fibrous particles etc. capable of forming an explosive atmosphere be present? Choose an item. If yes, what additional controls are required? Click here to enter text.
(28) Can less hazardous substances be used? Choose an item.
(29) Procedure for checking effectiveness of control measures Click here to enter text.
(30) If Carcinogens, mutagens or reproductive toxins (CMR), skin sensitisers, respiratory sensitisers, occupational asthmagens or nanoparticles are listed, is the fitness to work certificate for each individual still valid? Choose an item.	(31) If any of the Substances above are highly flammable and extremely flammable, What control measures are in place? Click here to enter text.
(32) Is lone working permitted for this procedure? Choose an item. If yes, what additional controls for lone working are required? Click here to enter text.	(33) Is out of hours working permitted for this procedure? Choose an item. If yes, what additional controls for out of hours working are required? Click here to enter text.
(34) Additional control measures or relevant information. Click here to enter text.
(35) Risk rating of the experiment: Choose an item.
Signatories We have discussed this chemical risk assessment and understand the hazards and the associated control measures required. A copy of this form must be displayed close to the reaction.
(36) Signature of Assessor: ……………………………………………………………………… (37) Signature of Approver: ……………………………………………………………………… (38) Signature of Verifier: ……………………………………………………………………… (where necessary)	Print Name: ………………………………………………………………………………… Print Name: ………………………………………………………………………………… Print Name: …………………………………………………………………………………	Date: …………………………………………………………… Date: …………………………………………………………… Date: ……………………………………………………………