DS-4319 - Activity Risk Assessment 19AJ2026Q0006.docx
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- Solicitation number
- 19AJ2026Q0006
- Issued by
-
Department of State US Embassy Baku
About this file
This is a DS-4319 Activity Risk Assessment form for the Asphalt Repair Project at the U.S. Embassy Baku, Azerbaijan (Solicitation 19AJ2026Q0006), dated April 13, 2026. The document is a template and instructional guide designed for contractors to identify, assess, and control risks and hazards associated with non-routine construction or maintenance activities at the embassy facility. The form requires contractors to complete a structured five-step risk management process: identifying hazards, assessing hazards, developing controls, implementing controls, and supervising/evaluating effectiveness. Contractors must document each subtask within their activity, specify associated hazards, determine initial risk levels using a provided risk assessment matrix, identify control measures, designate responsible individuals for implementation, and establish residual risk levels after mitigation.
The risk assessment matrix provided in the form categorizes risk by combining probability of occurrence (Improbable, Seldom, Occasional, Probable, Frequent) with severity levels (Negligible, Moderate, Critical, Catastrophic) to assign overall risk classifications ranging from Low to Extremely High. An example subtask addressing drilling ceiling penetrations and installing air conditioning unit brackets is provided, demonstrating how to document hazards such as working at heights, dust, and noise, along with corresponding controls like temporary scaffolding and personal protective equipment. The form allows contractors to assess up to 12 subtasks per submission, with provisions for additional forms if needed. Contractors must identify the overall residual risk level as the highest remaining risk after all controls are implemented and may provide additional comments to support their assessment. Questions regarding the risk assessment process should be directed to the Office of Safety, Health, and Environmental Management (SHEM) at SHEM-MRSAdmin@state.gov.
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Text version
Statement of Work Asphalt Repair Project at the U.S. Embassy Baku, Azerbaijan
19AJ2026Q0006
13 April 2026
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: | |
| 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 U.S. Department of State
Activity Risk Assessment
U.S. Department of State
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.
| 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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