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OPERATIONAL RISK ASSESSMENT WORKSHEET

1. MISSION: 2. DATE BEGIN: END: 5. PREPARED BY: 3. DATE PREPARED:

Page ______ of ______ 4. DESIGNATOR NUMBER:

RANK / LAST NAME/ DUTY POSITION

SIGNATURE

6. HAZARD: LIST YOUR POSSIBLE HAZARDS HERE

7. INITIAL RISK LEVEL: RAC CODE

8. WHAT ARE YOUR CONTROL FEATURES FOR THE LISTED HAZARD TO THE LEFT

9. RESIDUAL RISK LEVEL: RAC CODE AFTER CONTROLS

10. HOW TO IMPLEMENT: ANSWER THE ABOVE QUESTION

11. HOW TO SUPERVISE: LIST YOUR SUPERVISORY TOOLS HERE

12. CONTROLS EFFECTIVENESS: AAR COMMENTS

13. OVERALL RISK LEVEL AFTER CONTROLS ARE IMPLEMENTED: (Check One) 14. RISK DECISION AUTHORITY: RAC 1 (CRITICAL) RAC 4 (MINOR) RAC 2 (SERIOUS) RAC 5 (NEGLIGBLE) RAC 3 (MODERATE) RANK / LAST NAME/ DUTY POSITION PREVIOUS EDITIONS ARE OBSOLETE SIGNATURE

MCB Form 5100/12 (12/04) (EF)

Designed using Adobe Form Desi MCB/ADJ December 20

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