DS-4319 - Activity Risk Assessment 19AJ2026Q0016.docx
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- Attached to
- Wall, Floor, and Canopy Repairs at the Consular Section of the U. S. Embassy Baku, Azerbaijan.
- Solicitation number
- 19AJ2026Q0016
- Issued by
-
Department of State US Embassy Baku
About this file
This is an Activity Risk Assessment form (DS-4319) required as part of the Statement of Work for solicitation 19AJ2026Q0016 concerning wall, floor, and canopy repairs at the U.S. Embassy Baku Consular Section. The form serves as a template for contractors to identify, assess, and develop controls for all hazards and risks associated with the proposed work activities. The document includes a five-step risk management framework: identify hazards, assess hazards, develop controls, implement controls, and supervise/evaluate. Contractors must complete the assessment by describing each subtask or activity component, identifying associated hazards, determining initial risk levels using the provided risk assessment matrix, specifying mitigation controls, assigning responsibility for implementation, and calculating residual risk levels after controls are applied.
The form requires contractors to list up to twelve subtasks with corresponding hazard analysis, initial risk classification (ranging from Low to Extremely High based on probability and severity), and control measures. An example provided addresses drill penetrations and bracket installation for AC units, identifying hazards of working at heights, dust, and noise, with controls including temporary scaffolding, dust masks, and hearing protection. Contractors must assign an overall residual risk level representing the highest remaining risk after all controls are implemented and provide additional comments supporting the assessment. Incomplete or inadequately addressed risk assessments may affect proposal evaluation, as this document demonstrates the contractor's safety management approach for non-routine activities at the embassy facility.
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Text version
Statement of Work U.S. Embassy Baku Solicitation for Wall, Floor, and Canopy Repairs at the Consular Section
19AJ2026Q0016
23 July 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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