1. No category

Anytown Medical Facility
06/12/2015
RISK ASSESSMENT FORM 1
PHYSICAL & ENVIRONMENTAL THREATS
ENVIRONMENTAL / PHYSICAL THREAT-SOURCES
Likelihood
Impact

Hurricanes
Low
Moderate

Tornadoes
Low
Risk
Actions Taken
Low
3, 6, 10, 15
High
Moderate
3, 6, 10, 15
Moderate
Low
Low
10, 14
Low
High
Moderate
Low
Low
10, 14
Floods
Earthquakes

Electrical storms
Landslides
10

Fires

Power failures

Remodeling (dust, moving equipment, etc.)
Low
Low
Low
17

Water Damage, Plumbing Leaks
Low
Low
Low
10

System failure, Computer Crash
Low
Low
Low
10, 18
Actions Taken:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Unique User ID
Emergency Access
Automatic Logoff
Authentication
Encryption
Emergency Operation Plan
Access Controls
Audit Controls
Data Integrity
Data Backup
Disaster Recovery Plan
Video Cameras
Alarm System
Battery Backup
Police/Security Patrol
Employee Training
Business Associate Agreements, Confidentiality Statements
Firewalls, Antivirus
Check the threats that apply to your facility. To determine the ratings for Likelihood, Impact and Risk, refer to
Determine the Risk Levels Worksheet. Based on the Risk Level determine if action is required to mitigate
risks.
HIPAA Risk Assessment / Physical & Environmental Threats
Form 1