Attachement 2 DS-4319 Activity Risk Assessment.doc
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- Solicitation number
- 19AJ2026Q0014
- Issued by
-
Department of State US Embassy Baku
About this file
This is a DS-4319 Activity Risk Assessment form required as part of solicitation 19AJ2026Q0014 for the U.S. Embassy Baku Main Entrance (Post 2) Roof Repair Project. The form serves as a risk management tool for contractors to identify, assess, and control hazards associated with the roof repair activity. Contractors must complete the assessment by identifying all subtasks, specifying associated hazards, determining initial risk levels using the provided risk assessment matrix, developing control measures, designating implementation responsibility, and calculating residual risk levels after controls are applied. The form includes a five-step risk management process: identify hazards, assess hazards, develop controls, implement controls, and supervise/evaluate. An example subtask is provided showing drill penetrations in the ceiling and AC unit bracket installation, which presents hazards including complicated work at heights, dust, and noise, with controls such as temporary scaffolding, dust masks, and hearing protection, resulting in a medium residual risk level after implementation.
The form allows for up to 12 subtasks per page, with additional forms required if more are needed. Contractors must assign an overall residual risk level based on the highest remaining residual risk from all subtasks and may provide additional comments to support their assessment. This document is a template requirement for contractors responding to the solicitation and does not specify products or services; rather, it establishes the safety assessment framework that must accompany the contractor's proposal.
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ATTACHMENT #2 - DS-4319 Activity Risk Assessment
Exhibit A: DS-4319 Activity Risk Assessment
Instructions: Complete the following form using the instructions on page 4. The subtask in cell 4a.1 below is only an example. The Contractor must complete their own assessment to identify and control all risks and hazards. If there are more than 12 subtasks, use an additional form.
| 1. |
| Task/Activity Description: 19AJ2026Q0014 U.S. Embassy Main Entrance (Post 2) Roof Repair at the Chancery |
| 2. |
Date: (DD/MM/YYYY)
| 3. |
| Prepared By: |
| 3b. |
Title/Position
| 4. |
| Five Steps of Risk Management: (1) Identify the hazards (2) Assess the hazards (3) Develop controls (4) Implement controls (5) Supervise and evaluate |
See risk assessment matrix on page 3 for risk classification guidance.
| 4a. |
| Subtask in Activity |
| 4b. Hazard |
| 4c. Initial Risk Level |
| 4d. Control |
| 4e. Who Will Implement |
| 4f. Residual Risk |
| 1. |
| Drill penetrations in the ceiling and install brackets to mount new AC units |
| Complicated work from heights, dust, noise |
| High |
| Build temporary scaffolding, use dust masks, hearing protection |
| Insert on-site supervisor name |
| Medium |
2.
3.
4.
5.
| 4a. |
| Subtask in Activity |
| 4b. Hazard |
| 4c. Initial Risk Level |
| 4d. Control |
| 4e. Who Will Implement |
| 4f. Residual Risk |
6.
7.
8.
9.
10.
11.
12.
| 5. |
| Overall Residual Risk Level (Highest remaining residual risk level in block 4f.) |
Extremely High High Medium Low
Risk Assessment Matrix
Probability of Occurrence
Improbable:
(Very Unlikely to Occur) Seldom:
(Not Likely to Occur) Occasional:
(Sporadic or Intermittent Occurrences) Probable:
(Likely to Occur Multiple Times) Frequent:
(Regular or Continuous Occurrence)
Severity
Negligible:
No Injury or Damage
| Low |
| Low |
| Low |
| Low |
| Medium |
Moderate:
Minor Injury or Damage
| Low |
| Low |
| Medium |
| Medium |
| High |
Critical:
Major Injury or Damage
| Low |
| Medium |
| High |
| High |
| Extremely High |
Catastrophic:
Death, Permanent Disability, or Interrupted Operations
| Medium |
| High |
| High |
| Extremely High |
| Extremely High |
6.
Additional Comments:
U.S. Department of State Bureau of Overseas Buildings Operations, OPS/SHEM, SA-6 Washington, DC 20522-0611 Activity Risk Assessment Instructions Page. For information or questions please contact the Office of Safety, Health, and Environmental Management (SHEM) at SHEM-MRSAdmin@state.gov.
19AJ2026Q0014 July 27, 2026
| 1. Task/Activity Description: Briefly describe the overall Task or Activity for which the risk assessment is being conducted. This form is not intended to replace job specific JHAs rather to provide a tool for managing non-routine activity risk. |
| 4d. Control: Identify risk mitigation resources/controls to abate or reduce risk for all hazards in block 4b (i.e., removal of hazards, administrative controls, training, PPE, etc.) |
| 2. Date (DD/MM/YYYY): Self explanatory. |
| 4e. Who Will Implement: The name of the individual that has primary responsibility for control implementation. |
| 3. Prepared By: The individual conducting the risk assessment. |
| 4f. Residual Risk Level: After controls are implemented, determine resulting probability, severity, and residual risk level (use the risk assessment matrix on page 3) |
| 4a. Subtask in Activity: Briefly describe all subtasks or different parts of the activity that warrant risk management. Keep it as simple as possible, but with enough information to identify the task. |
| 5. Overall Residual Risk Level: Assign an overall residual risk level after controls are implemented. This is the highest residual risk level (from block 4f). |
4b. Hazard: Specify hazards related to the subtask in block 4. A common mistake is to refer to a hazard as the actual harm or the health effect it caused rather than the hazard. If the task was mopping the floor, the hazard is the wet floor not the potential harm caused e.g. fall / cut knee. If no hazards exist, the task still needs to be listed
| 4c. Initial Risk Level: Using the risk assessment matrix (page 3), determine level of risk for each hazard specified. Use the probability, severity, and associated Risk Level and write the highest level |
| 6. Additional Comments: Additional comments, remarks, or information to support the risk assessment. |
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