Healthcare IT System Risk Assessment Form

General Information

Assessment Date Assessor Name Department System/Application Name System Owner

System Description

Purpose of the System Criticality Level Low Moderate High

Identified Risks

Risk Description	Likelihood	Impact	Controls	Residual Risk
	Low Medium High	Low Medium High		Low Medium High
	Low Medium High	Low Medium High		Low Medium High

Recommendations

Summary of Recommendations

Approval

Approver Name Approval Date Signature