Risk assessment tables — examples

Table 1. Qualitative risk estimation

Phases of use

Hazardous situations

Hazards

Dangerous events

Estimation of the severity of damage

Estimation of the

probability of damage

Risk estimation

Risk evaluation

Acceptable risk

YES/NO

Sources

Potential consequences of the action

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 2. Quantitative risk estimation

Phases of use

Hazardous situations

Hazards

Dangerous events

The measurement result of a measurable factor and its reference to the exposure limit values

Risk estimation

Risk evaluation

Acceptable risk

YES/NO

Sources

Potential consequences of the action

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 3. Risk assessment based on requirements set out in standards

Harmonized standards

Evaluation of fulfilment of the requirements set out in standards

Risk evaluation

Acceptable risk — YES/NO

 

 

 

 

 

 

 

 


 

Attachment No 13: Risk assessment template form in the conformity assessment process

Logo of the project

 

 

Form symbol

 

XXX

Machine ID

 

XXX-XXX

Form date

(start date of assessing compliance with the essential requirements)

xxxx-xx-xx

Machine name, type or series of types of the machine

 

Description of the machine (intended use)

 

Information about the limitations of the machine

 

Information about prohibited methods of operation

 

Checklist of requirements (in accordance with the 2006/42/EC directive)

 

Requirement number

 

 

Item in accordance with the directive

 

 

Requirement:

 

Applies to the machine

(Yes/No)

 

Requirement fulfilled

(Yes/No)

 

Number of hazardous situation

 

1

Hazardous situation

(Description)

Risk assessment basis

(Standards or other documents used for risk assessment and selection of safety measures)

Safety measures used

a) solutions safe by themselves

 

 

b) technical safety measures (basic and supplementary)

 

 

c) safety measures to be implemented by the user

Information about residual risks

 

Requirement fulfilled in relation to the hazardous situation

(Yes/No)

 

Risk assessment type

(a) Assessment in accordance with type C standard

b) Assessment in accordance with the EN ISO 12100:2010 standard and type B standards

c) Assessment directly in accordance with the 2006/42/EC directive

Risk assessment result

(Indication of a document containing detailed information or indication of a declaration of conformity or a declaration of partly completed machine, based on which the fulfilment of the requirements was determined)

Information for user

 

Number of hazardous situation

 

...

Hazardous situation

(Description)

Risk assessment basis

(Standards or other documents used for risk assessment and selection of safety measures)

Safety measures used

a) solutions safe by themselves

 

 

b) technical safety measures (basic and supplementary)

 

 

c) safety measures to be implemented by the user

Information about residual risks

 

Requirement fulfilled in relation to the hazardous situation

(Yes/No)

 

Risk assessment type

(a) Assessment in accordance with type C standard

b) Assessment in accordance with the EN ISO 12100:2010 standard and type B standards

c) Assessment directly in accordance with the directive

Risk assessment result

(Indication of a document containing detailed information or indication of a declaration of conformity or a declaration of partly completed machine, based on which the fulfilment of the requirements was determined)

Information for user

 

 


 

Attachment No 14: Safety functions assessment template form in accordance with EN ISO 13849-1:2008

Logo of the project

 

Form symbol

 

XXX

Machine ID

 

XXX-XXX

Form date

(start date of assessing compliance with the essential requirements)

xxxx-xx-xx

Machine name, type or series of types of the machine

 

Name/ID of a security function

 

Hazardous situations during normal and incorrect use

 

Description of a security function (functional assumptions)

 

Checklist of requirements regarding control-based safety measure
(EN ISO 13849-1:2008 and EN ISO 13849:2012 standards)

 

Risk assessment — determining the required performance level

Severity of the damage

(S1/S2)

Frequency of exposure

(F1/F2)

Possibility of avoiding the damage

(P1/P2)

Required performance level PLw (a, b, c, d, e)

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Determination of design requirements relating to the safety functions

Category

(B, 1, 2, 3, 4)

Mean time to dangerous failure (MTTF)

(low, average, high)

Diagnostic coverage (DC)

(-, low, average, high)

 

Designer’s approval

(Yes/No)

 

Validator’s approval

(Yes/No)

 

The definition of technical and environmental conditions and influence of recycled materials, taking into account the limits of the machine

Documentation confirming the requirement

 

 

Safety plan

Documentation confirming the requirement

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Design documentation of safety functions (block, schematic, assembly diagrams of systems, functional description, signals time sequence diagrams)

Documentation confirming the requirement

Designer’s approval

(Yes/No)

 

Validator’s approval

(Yes/No)

 

Determining the type of power supply used in a safety-related control system

Electricity powered systems

(Yes/No)

Pneumatic powered systems

(Yes/No)

Hydraulic powered systems

(Yes/No)

Mechanical systems

(Yes/No)

Designer’s approval

(Yes/No)

 

Validator’s approval

(Yes/No)

 

Software of a safety-related control system

Relates to the design

(Yes/No)

Documentation confirming the requirement

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Elements used in the safety functions design

Documentation confirming the requirement

Achieved mean time to dangerous failure (MTTF)

(low, average, high)

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Dangerous defects in the designed safety function implementation

Documentation confirming the requirement

Achieved diagnostic coverage (DC)

(-, low, average, high)

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Safety rules included in the security functions design

Documentation confirming the requirement

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Damages due to a common cause

Relates to the design

(Yes/No)

Documentation confirming the requirement

The level of damage from a common cause

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Measures to prevent systematic defects

Documentation confirming the requirement

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Laboratory tests and prototype tests

Documentation confirming the requirement

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Software tests

Relates to the design

(Yes/No)

Documentation confirming the requirement

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Other requirements

Relates to the design

(Yes/No)

Documentation confirming the requirement

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Description of safety functions for the user and procedures of checking the safety functions

Documentation confirming the requirement

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Determining the achieved performance level (PL)

Achieved performance level (PL)

(a, b, c, d, e)

Confirmation of achieving the determined design objective

(Yes/No)

Designer’s approval

(Yes/No)

Validator’s approval

(Yes/No)

Validation report

Documentation confirming the requirement

 

Validator’s approval

(Yes/No)

 

Safety function designers

..........................................

..........................................

Signatures:

............................................

............................................

Safety function validators

..........................................

..........................................

Signatures:

............................................

............................................

The safety-related control system executing the safety function meets the requirements

(Yes/No)

 

Summary of assessment form of compliance with essential requirements as set out by the 2006/42/EC directive

The assessors carrying out the assessment of meeting the essential requirements

..........................................

..........................................

Signatures:

............................................

............................................

Related documents

 


Attachment No 15: The list of specific risks concerning woodworking machines and materials of similar physical characteristics in accordance with the 42/2006/EC directive

Requirement concerning

Area/element of the machine

Effects

·         object stability;

·         ease of manual feed;

·         table;

·         technological handle;

·         recoil (impact);

·         recoil — contact with the tool (cutting, cut), loss of balance — contact with the tool (cutting, cut), fall (impact);

·         contact with moving parts of the machine (being pulled into, entangled, crushed, etc.);

·         eliminating the risk of recoil;

·         cutting tool;

·         workpiece;

·         recoil (body impact);

·         recoil — contact with tool (cutting, cut);

·         recoil — acceleration (joint dislocation, bruise);

·         ejection of splinters, knots (getting into eyes, facial injuries)

·         retardation of the tool

·         tool brake

·         cutting tool area;

·         drive of the tool components

·         contact with tool (cutting, cut);

·         contact with moving parts of the machine (being pulled into, entangled, crushed, etc.);

·         tool built into the machine with the feed and/or manual feed

·         cutting tool area

·         contact with tool (cutting, cut)

·         recoil (impact);

·         recoil — contact with the tool (cutting, cut), loss of balance — contact with the tool (cutting, cut), fall (impact);

 

 

 

 


 

Attachment No 16: The list of specific risks concerning portable hand-held or hand-guided machines in accordance with the 42/2006/EC directive

Requirement concerning

Area/element of the machine

Effects

·         stability of the machine during its operation

·         whole manually operated machine

·         loss of balance — contact with tool (cutting, cut);

·         recoil (kick) of the machine (impact, cut, cutting);

·         fall of the machine on the operator’s legs (impact, crushing)

·         manual control devices for starting and stopping the machine with the handles

·         whole manually operated machine

·         loss of balance — contact with tool (cutting, cut);

·         recoil (kick) of the machine (impact, cut, cutting);

·         fall of the machine on the operator’s legs (impact, crushing)

·         elimination or limitation of risk of accidental start-up or further operation of the machine after the operator releases the handles

·         whole manually operated machine

·         loss of balance — contact with tool (cutting, cut);

·         recoil (kick) of the machine (impact, cut, cutting);

·         fall of the machine on the operator’s legs (impact, crushing)

·         the possibility of visual observation of the cutting zone

·         whole manually operated machine

·         loss of balance — contact with tool (cutting, cut);

·         recoil (kick) of the machine (impact, cut, cutting);

·         fall of the machine on the operator’s legs (impact, crushing)

 

 


 

Attachment No 17: List of significant risks, which may be created by the woodworking machine in accordance with the type C standards (example)

 

No

Hazards, hazardous situations and hazardous events

EN ISO 12100:2010

Relevant section of the type C standard

1

Mechanical hazards caused by:

- woodworking machine parts or workpieces:

 

a)  shape;

6.2.2.1, 6.2.2.2, 6.3

5.3.3, 5.3.5, 5.3.7, 5.4.5

 

 

b)  location;

5.2.2, 5.3.3, 5.3.5, 5.3.6, 5.3.7, 5.4.3, 5.4.5

 

 

d) mass and velocity (kinetic energy of parts which move in a controlled or uncontrolled manner);

5.3.3, 5.3.7

e)  mechanical strength.

5.3.2, 5.3.3

energy accumulation inside the machine:

 

f) elastic elements (springs);

6.2.10, 6.3.5.4

5.3.3.5

 

g) liquids and gases under pressure;

5.2.5, 5.3.7, 5.4.12

1.1

Risk of being crushed

 

5.3.6

1.2

Risk of cutting off

5.3.6

1.3

Risk of cutting or incision

5.3.3.5, 5.3.3.6,

5.3.6

1.4

Risk of entanglement

5.3.6

1.5

Risk of being pulled into or seized

5.3.6

1.6

Risk of being struck

5.3.7

1.7

Risk of puncture or perforation

 

5.3.6.1

1.8

Risk of abrasion

 

5.3.6.1

1.9

Risk of fluid ejection under high pressure or risk of spurts

6.2.10

5.4.6

2

Electrical hazards caused by:

2.1

Contact of persons with live parts (direct contact)

6.2.9, 6.3.5.4

5.4.4

2.2

Contact of persons with parts which may be live due to a fault (direct contact)

6.2.9

5.4.4

2.4

Electrostatic phenomena

6.2.9

5.4.9

4

Noise hazards causing:

4.1

Hearing loss (deafness) and other physiological symptoms (e.g. loss of balance, loss of consciousness)

6.2.2.2, 6.3

5.4.2

4.2

Disturbances in verbal communication, perception of acoustic signals

5.4.2

6

Hazard caused by radiation

6.5

Lasers

6.3.4.5

5.4.8

7

Hazards caused by materials and substances (and their components), processed by or used by the woodworking machine:

7.1

Hazards arising from touching or inhalation of harmful fluids and dusts

6.2.3, 6.2.4

5.4.3

7.2

Risk of fire

6.2.4

5.4.1

8

Hazards resulting from neglecting the principles of ergonomics in the design of the machine:

8.1

Postures harmful to health or excessive effort

6.2.7, 6.2.8, 6.2.11.12, 6.3.5.5, 6.3.5.6

5.2.2, 5.4.5

8.2

Anatomy of the arm/hand or leg/foot

6.2.8.3

5.4.5

8.6

Human errors and behaviour

6.2.8, 6.2.11.8,

6.2.11.10, 6.3.5.2, 6.4

5.2.1, 5.2.3,

5.4.10

8.7

Design, location or identification of manual controls

4.8.7, 4.11.8

5.2.2, 5.4.11

8.8

Design or location of displays

6.2.8.8, 6.4.2

5.3.3.5,

5.4.5

10

Unexpected start, unexpected overspeed / excessive speed (or other similar faults) caused by:

10.1

Fault/malfunction of the control system

6.2.11, 6.3.5.4

5.2.1

10.2

Uncontrolled restoring of power supply after an interruption

6.2.11.4

5.2.5

10.3

External influences on the electrical equipment

6.2.11.11

5.4.7

10.6

Operator errors (caused by the discrepancy of the machine and human capabilities and capacities, see item 8.6)

6.2.8, 6.2.11.8, 6.2.11.10, 6.3.5.2, 6.4

5.4.10, 6.3

11

Inability to stop the woodworking machine in the best conditions possible

6.2.11.1, 6.2.11.3, 6.3.5.2

5.2.4, 5.3.4

13

Faulty power supply

6.2.11.1, 6.2.11.4

5.2.5

14

Faulty control system

6.2.11, 6.3.5.4

5.2.1

15

Installation errors

6.2.7, 6.4.5

5.4.10

16

Breaking up [of the tool] during operation

6.2.3

5.3.2, 5.3.3

17

Falling or ejected parts

6.2.3, 6.2.10

5.3.3.5

18

Loss of stability /overturning of the woodworking machine

6.3.2.6

5.3.1

 


 

Attachment No 18: Hazards associated with laser radiation: sources and potential consequences (examples)

Hazards (sources and potential consequences of hazards) should be identified using the following list. Hazards should be determined for all tasks (hazardous situations) identified for all phases of machine use.

Laser radiation → sources

·        Direct laser radiation ranging from 400 nm to 600 nm (visible) of accessible emission limit (AEL) above the level for class 3R.

·        Direct or reflected laser radiation ranging from 780 nm to 1400 nm (invisible) of accessible emission limit (AEL) above the level for class 3R.

·        Reflected laser radiation ranging from 780 nm to 1400 nm (invisible)

Laser radiation → potential consequences of hazards

·        Thermal damage to the retina (loss of sight)

·        Photochemical damage to the retina (loss of sight)

·        Thermal or photochemical damage to the retina (loss of sight)


 

Attachment No 19: Checklist template for laser device in the machine

Machine name/type

 

Manufacturer

Intended use of the machine:

Type of the laser device installed in the machine:

 

Parameters of the laser installed in the machine:

¾    Class

¾    Mode of operation

¾    Length of single pulse

¾    Repetition rate

¾    Max power/energy

 

 

Full name of the evaluating person

Date of the assessment

Item

Question

Yes

No

Not applicable

 

1

Measurement in order to determine the laser safety class

 

 

 

 

1.1

Have the measurements in order to determine the laser safety class been conducted?

 

 

 

 

1.2

If not, is it considered that these measurements do not need to be performed, as the laser installed inside the machine has a specific measuring laser safety class and the laser safety class of the machine has not changed?

 

 

 

 

1.3

If the answer in 1.1 and 1.2 is “yes”, determine:

¾    Wave length (of wave length range) of available laser radiation

¾    Maximum level of available laser radiation

 

λ=        nm

 

 

P=…………..W

Q=……………J

 

1.4

Determined laser safety class

 

 

1.5

Are the measurements results attached?

 

 

 

 

1.6

Are the results of the accessible emission limit (AEL) attached?

 

 

 

 

2

The labels on the machine according to the determined laser safety class (in accordance with PN-EN 60825-1)

 

 

 

 

2.1

Are there labels located in relevant places on the machine, in accordance with the determined laser safety class (in accordance with PN-EN 60825-1 and IER/TR 60825-5)?

 

 

 

 

3.

Technical documentation

 

 

 

 

3.1

Is the laser device equipped with protective housing to protect a man from accessing the laser beam?

 

 

 

 

3.2

Is the class 3B or 4 laser equipped with a remote lock switch?

 

 

 

 

3.3

Is the class 3B or 4 laser started with a key?

 

 

 

 

3.4

Is the class 3R or 4 laser equipped with a device warning about emission?

 

 

 

 

3.5

Is the class 3B or 4 laser equipped with permanently built-in beam limiter?

 

 

 

 

3.6

Is the class 3R, 3B or 4 laser equipped with position control, so that there is no risk of exposure to AEL higher than class 1 and class 2, when adjustments are made?

 

 

 

 

3.7

If the device is equipped with visual optics, is the emission from all visual systems below the AEL for class 1M?

 

 

 

 

3.8

Is the device equipped with a tool for scanning emitted laser radiation?

 

 

 

 

3.9

If the answer in 3.8 is “yes”, has this been taken into consideration during device classification?

 

 

 

 


 

Attachment No 20: Checklist for integral lighting equipment

Item

Control question

NO

RISK

NOTE

1

Is it necessary to provide additional lighting for specific working areas of the machine?

 

average

 

high

Risk classification in accordance with annex 21.1.

 

2.

Does the light emitted through the local lighting luminaire meet the requirements of the machine working area in which the visual work is performed?

 

average

 

high

Risk classification in accordance with annexes 21.1. and 21.2.

 

3. 

Does the used local lighting luminaire provide a good degree of lighting of the machine working area in which the visual work is performed?

 

average

 

high

Risk classification in accordance with annex 21.

4. 

Does the local lighting luminaire provide a good degree of lighting of the areas, in which the adjustment, setting and frequent maintenance are carried out?

 

average

 

high

Risk classification in accordance with annex 21.

5. 

Does the installed local lighting cause direct glare (does the source of light shine directly into the eyes of an employee)?

 

average

 

high

Risk classification in accordance with annex 21.3.

6. 

When performing common tasks during machine operation, are there any visible bright light sources?

 

average

 

high

Risk classification in accordance with annex 21.3.

7. 

Do shiny structural components of machines cause reflective glare?

 

average

 

high

Risk classification in accordance with annex 21.3.

8. 

Does the design of the machine and/or guards cause that the local lighting does not reach all the required works areas?

 

average

 

high

Risk classification in accordance with annex 21.2.

9.

Does the position of local lighting luminaire cause any dangerous shadows in the vicinity of the machine?

 

average

 

high

Risk classification in accordance with annex 21.2.

10. 

Do the light sources used in the local luminaire cause distortion to the colour of details?

 

average

 

high

Risk classification in accordance with annex 21.4.

11.

Does the colour rendering index (Ra) of light sources used in the luminaire meet the normative requirements?

 

average

 

high

Risk classification in accordance with annex 21.4.

12. 

Is the colour of the light emitted by the light sources installed in the luminaire pleasant (2,700–4,000 K)?  

 

 

-

 

annex 21.4.

13. 

Is flickering of the light noticeable?  

 

average

 

 

Risk classification in accordance with annex 21.5.

14. 

Is pulsating of light noticeable?  

 

average

 

 

Risk classification in accordance with annex 21.5.

15.

Is the occurrence of stroboscopic effect caused by rotation of the elements of the machine possible when the local lighting luminaire is turned on?   

 

 

high

Risk classification in accordance with annex 21.5.

16.

Is the occurrence of stroboscopic effect caused by reciprocating movement of the elements of the machine possible when the local lighting luminaire is turned on?   

 

 

high

Risk classification in accordance with annex 21.5.

17. 

Does adjusting the luminaire part (if present) with the light source pose risk for people adjusting the luminaire (burns caused by the lampshade)?

 

 

average

 

 

Risk classification in accordance with annex 21.7.

18. 

Does adjusting the luminaire part (if present) with the light source pose any risk of scratching or squeezing a finger, etc.?

 

 

average

Risk classification in accordance with annex 21.7.

19.

Is the luminaire blocked after the adjustment and does not go back to the previous position or a position which interferes with work?

 

 

average

 

Risk classification in accordance with annex 21.7.

20.

Is the power supply of a luminaire made in a manner safe for the user?   

 

average

 

high

average SELV

 

high 230 V

21.

Is the installation of a luminaire made in a manner safe for the user?

 

average

 

high

average SELV

 

high 230 V

Risk classification in accordance with annex 21.6.

22.

Can the arrangement of cables result in any cable damage during the operation of the machine?

 

average

 

high

average SELV

 

high 230 V

Risk classification in accordance with annex 21.6.

 

Attachment No 21: Criteria for assessing the risks associated with integral lighting equipment

21.1. Criteria for assessing the illuminance-related risks

 

Risk level

Illuminance, lx

Required by the standard

(EPN)

Determined in the area of the machine operation

(Ez)

 

 

Low

EPN ³ 750

Epz ³ 0.8 × EPN,

EPN = 500

Epz ³ 400

EPN = 300

Epz ³ 240

EPN £ 200

Epz ³ 0.8 × EPN,

 

 

Average

EPN ³ 750

0.8 × EPN > Epz ³ 0.2 × EPN

EPN = 500

400 > Epz ³ 100

EPN = 300

240 > Epz ³ 60

EPN £ 200

0.8 × EPN > Epz ³ 0.2 × EPN,

 

 

High

EPN ³ 750

Epz < 0.2 × EPN,

EPN = 500

Epz < 100

EPN = 300

Epz < 60

EPN £ 200

Epz < 0.2 × EPN,

 

 

 

 

21.2. Criteria for assessing the uniformity of illumination-related risks

Risk level

Area of the task (U0)

Low

      U0 ³ 0.8 × U0PN

Average

0.2 × U0PN £ U0 < 0.8 × U0PN

High

                  U0 < 0.2 × U0PN

 

21.3. Glare-related risk assessment

Risk level

Determined maximum value of luminance

L, kcd/m2

Low

50 > L ³ 20

Average

500 > L ³ 50

High

L ³ 500

 


 

21.4. Criteria for assessing the risks associated with a colour rendering index

Required colour rendering index value

Determined colour rendering index value Ra

Risk level

 

³ 90

       Ra ³ 90

low

        Ra < 90

average

 

               ³ 80

        Ra ³ 80

low

        Ra < 80

average

 

³ 60

      Ra ³ 60

low

               Ra < 60

average

 

³ 40

      Ra ³ 40

low

               Ra < 40

average

 

³ 20

        Ra ³ 20

low

         Ra < 20

average

 

21.5. Criteria for assessing the risks related to flickering, pulsating and stroboscopic effects

It should be assumed that average risk related to flickering/pulsating of light exists, when at least one of the following events occurs:

·        noticeable flickering/pulsating of light has been determined

·        luminaires are not equipped with anti-stroboscopic effect device and they are sectioned and powered from three-phase mains

·        luminaires are not equipped with electronic stabilization and ignition system.

When the stroboscopic effect was determined in the room where there are machines equipped with rotating or reciprocating elements, it should be assumed that the risk is high.

 

 

 

 

21.6. Power supply

If the employee operating a certain machine may be exposed to electric shock, it should be assumed that in the case of powering the luminaire with SELV the risk is average, and in the case of powering the luminaire from mains — the risk is high.

21.7. Functionality of luminaires

If the employee operating a certain machine may be exposed to burns, squeezing a finger, etc., in such cases it must be assumed that the risk is average.

 


 

Attachment No 22: Template document for assessing the risks associated with integral lighting equipment

 

1.    Date of the assessment

2.    Name of the machine

3.    Determination of the area/areas of the machine where the visual work is carried out

4.    Is the machine equipped with a local lighting luminaire?

5.    Is the local luminaire integrated with the machine, or is it a separate part?

6.    Is the position of the luminaire part with the light source adjustable?   

7.    Is it easy to adjust the luminaire part with the light source — does it require any tools?   

8.    Determining the occupational risk for the following parameters:

·        Illuminance -

·        Uniformity of illumination -

·        Glare -

·        Colour rendering -

·        Flickering, pulsating and stroboscopic effects -

·        Power supply -

9.    Assessment of functionality of luminaires –

 

10. Proposed corrective actions related to:

·        Illuminance -

·        Uniformity of illumination -

·        Glare -

·        Colour rendering -

·        Flickering, pulsating and stroboscopic effects -

·        Power supply -

·        Functionality of luminaires –

 

11. Final risk assessment for the whole machine (based on the checklist):

 

12. Full name of the person performing the assessment, signature