Individual Risk Assessment form Individual Risk Assessment form Please enable JavaScript in your browser to complete this form. Individual Risk Assessment Form Individual Risk Assessment Form Territory Disability Services Participant Information Participant Name and File Number Email Address Phone Number Date of Birth Assessment Date Contact Info in Emergency Review Date Other Relevant Notes Risk Areas Risk Area Yes No Degree of Dependency Hazards & Actions Required Completed (Date) By Whom Communication Low Med High Hearing OK LowMedHigh Speech OK LowMedHigh Able to write LowMedHigh English language skills LowMedHigh Repeat rows for each listed risk area as per the form (up to “Others”). Assessment Completed By Name Signature Role Date Submit Reset Submit
