Name of trainee: Registry/ID: Department: Date: Supervisor: Level of instruction: Physical risk Group1 Chemical risk Group 2 Biological risk Group 3 Ergonomic risk Group 4 Accidental risk Group 5 Example:Monitoring ofsealedsourceimplant(radionuclide) Example: Contact with chemical agent Example: Contact with patientswith a possiblerespiratory infection.Contact with contaminated blood. Cleaninglitter andrestroomafter patientuse. Example: Care of anxious patient, stressed patient Example: Inadequate use of  Personal Protective Equipment (PPE) and lack of shield

Table 2: Questionnaire to be fill out by the trainee to register the type of the risk identified. The professional in training must identify the activity that is associated with the risk identified under the supervision of the accident prevention committee or technician in charge of the sector/company