AI Impact Assessment Form: Downloadable

We have prepared this Template as an example AI impact assessment form that can be used to create a structured evaluation process to analyse the potential consequences, benefits and risks associated with the deployment of “High Risk Uses” of AI technologies.
It has been created for organisations to help ensure that AI technologies are employed in ways that uphold ethical standards, maintain privacy and security, and respect legal boundaries. The goal is to ensure responsible and informed decision-making when implementing AI technologies.

For the purpose of this Template, “High Risk Use” of AI technologies refers to situations where the use of AI technologies poses significant potential harm, ethical concerns or negative consequences.

High Risk Uses of AI technologies include but are not limited to using AI technologies:

  1. In any activity that is regarded as highly intrusive on the privacy of individuals, such as tracking or monitoring an individual without their consent, and use of biometrics for identification or assessment;
  2. For automated decision-making processes with legal or similarly significant effects;
  3. For generating individualised advice that in the ordinary course of business would be provided by a licensed professional. This includes, for example, financial, legal or medical advice;
  4. For processing an individual’s sensitive characteristics or attributes. This includes using AI. Tools to generate predictions based on or using racial or ethnic background, past, current or future political inclinations, religious or philosophical beliefs, trade union membership, age, gender, sex life, sexual orientation, disability, health status, medical condition, financial status, criminal convictions, or the potential to engage in criminal acts;
  5. In any capacity in the context of job hiring and candidate selection, that could supplant or significantly influence the decision-making role of a HR hiring team. This may include the screening or comparative assessment of candidate information, profiles, or resumes;
  6. For direct communication or engagement with any individual.

As at the date of this Template, the landscape of AI laws and regulations remains in a state of continual evolution. Notably, the EU has introduced the Artificial Intelligence Act (AI Act), which is likely to be the first legal framework for the use of AI globally. It is paramount that you remain vigilant in seeking legal updates and verify that the use of AI within your organisation aligns with prevailing compliance requirements.

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The downloadable will be immediately available below once you complete the form. You will also receive a copy via email.


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Privacy, security and training. Jodie is one of Australia’s leading privacy and security experts and the Founder of Privacy 108 Consulting.