You are on page 1of 32

Contents

1. Examples of risk assessment forms


a. General Risk assessment form
b. Risk assessment report form example
c. Contractors risk assessment example for confined spaces NIB
d. Contractors risk assessment example for work on fragile roofs NIB
e. Maciner! risk assessment example NIB
". #ob safet! anal!sis form
$. Essential elements of a permit%to%work form
&. 'n example of a set of C()** assessment forms
a. C()** 1 % +E,'I-) (. )/B),'NCE) /)E+ (R ),(RE+
b. C()** " % '))E))MEN, (. ' )/B),'NCE
0. Example of a workstation self%assessment cecklist 1+)E2
3. Example of a noise assessment record form
4. Example of a workplace inspection report form
5. 6orkplace inspection cecklist
7. 'ccident8incident report form
19. Man:al andling of loads assessment cecklist
11. Man:al andling risk assessment
1". Example fire safet! maintenance cecklist NIB
1$. Example fire risk assessment record of significant findings
1&. Constr:ction inspection report form
1
1 (a) General Risk assessment form
General Health and Safety Risk Assessment
Example 1
No
Firm/Compan
y
Departmen
t
Contact
Name
Nature of
Business
Telephone
No
Principal Hazards
1
2
3
4
5
Persons at Risk
Main e!al Re"uirements
1
2
3
4
5
#i!ni$cant Risks Conse"uences
1
2
3
4
5
%&istin! Control Measures
'
(
)
*
+
Residual Risk, i-e- after controls are in place-
#e.erity ikelihood Residual
risk
/nformation rele.ant H#% and trade pu0lications
Comments from ine Mana!er Comments from Risk 1ssessor
Signed Date Signed Date
Reie! Date
"
(") Risk Assessment Report #orm
Name of Compan!; +ate of 'ssessment;
Name of 'ssessor; +ate of Re<iew;
*a=ards
>ersons
affected
Risks
Initial Risk
-e<el
Existing Controls 'dditional Controls
'ction b!
wom?
'ction b!
wen?
+one
$
2c3 Contractors4 risk assessment e&ample for con$ned spaces
$%$&$A' R$S( ASSESS)E%&
*ork in Confined Spa+es
S$G%$#$CA%& HA,ARDS 'o! )edi-m High
1. >oisoning from toxic gases
/. 'sp!xiation % lack of ox!gen
0. Explosion
1. .ire
2. Excessi<e eat
3. +rowning
4.
5.
AC&$6% A'READ7 &A(E% &6 RED8CE &HE R$S(S9
Complian+e !ith9
* ) E G:idance Note % Entr! into Confined )paces
-ocal ':torit!8client safet! standards@ e.g. on sewer entr!.
Entr! into Confined )paces Reg:lations 1774
,e Constr:ction 1+esign and Management2 Reg:lations "994
+angero:s ):bstances and Explosi<e 'tmosperes Reg:lations.
:lanning9
Eliminate need for entr! or :se of a=ardo:s materials b! selection of alternati<e metods of work or materials.
'ssessment of <entilation a<ailable and possible local exa:st <entilation reA:irements@ potential presence of
a=ardo:s gases8atmospere@ process b!%prod:cts@ need for impro<ed !giene8welfare facilit!.
:hysi+al9
+oc:mented entr! s!stem will appl!@ wit a >ermit to 6ork. 'deA:ate <entilation will be present or arranged.
+etection eA:ipment will be present before entr! to ceck on le<els of ox!gen and presence of toxic or explosi<e
s:bstances. ,e area will be tested before entr! and contin:all! d:ring te presence of persons in te confined
space. Breating apparat:s or airlines will be pro<ided if local <entilation is not possible. 6ere no breating
apparat:s is assessed as being reA:ired@ emergenc! B' and resc:e arnesses will be pro<ided. Resc:e
eA:ipment incl:ding lifting eA:ipment@ res:scitation facilities safet! lines and arnesses will be pro<ided. '
comm:nication s!stem wit tose in confined space will be establised. 'ir will not be sweetened wit p:re
ox!gen. >reca:tions for safe :se of an! plant or ea<ier%tan%air gases in te confined space m:st be establised
before entr!. Necessar! > >E and !giene facilities will be pro<ided for tose entering sewers.
)anagerial;S-perisory9
,e management role is to decide on nat:re of te confined space and to p:t a safe s!stem into operation@
incl:ding cecking te abo<e. .lood potential and isolations m:st be cecked.
&raining9
.:ll training reA:ired for all entering and managing confined spaces. Resc:e s:rface part! to be trained@ incl:ding
first aid and operation of testing eA:ipment. 'll operati<es m:st be certified as trained and s:per<isor! staff trained
to te same standard.
Risk Re<Assessment Date............................. Site )anager=s Comments9
&
2d3 Contractors4 risk assessment e&ample for 5ork on Fra!ile Roofs 6
e&ample *
$%$&$A' R$S( ASSESS)E%&
*ork on #ragile Roofs
S$G%$#$CA%& HA,ARDS 'o! )edi-m High
1. .alls of persons tro:g materials
/. 'ccess across fragile material
0.
1.
2.
3.
4.
5.
AC&$6% A'READ7 &A(E% &6 RED8CE &HE R$S(S9
Complian+e !ith9
-ifting (perations B -ifting EA:ipment Reg:lations. 1- ( - E R2
>ro<ision and /se of 6ork EA:ipment Reg:lations. 1> / 6 E R2
6ork at *eigt Reg:lations "990
* ) E G:idance Booklet *) 1G2 $$ % )afet! in Roof work
Constr:ction 1+esign and Management2 Reg:lations "994.
:lanning9
.ragile materials will be identified before work begins. In eac case@ an assessment of risk will be made to pro<ide
a safe s!stem of work taking acco:nt te work to be done@ access8egress reA:irements and protection of te area
beneat te work area.
:hysi+al9
):itable means of access will be pro<ided@ s:c as roof ladder@ crawling boards@ scaffolding@ and staging. 6ere
access is possible alongside fragile materials s:c as roof ligts@ co<ers will be pro<ided or te fragile material will
be fenced off@ catc nets will be pro<ided as appropriate. Barriers and signs will be pro<ided so as to isolate te
area below fragile materials wile work is in progress. No person is permitted to walk :pon s:spected fragile
materials for an! p:rpose@ incl:ding access and s:r<e!ing.
)anagerial;S-perisory9
,e role of management is to define a safe work metod prior to commencement of work@ and to arrange for
pro<ision of s:itable access eA:ipment and trained personnel as reA:ired b! te safe s!stem de<ised. Managers
m:st ceck risk assessments and metod statements s:pplied b! s:bcontractors and oters@ incl:ding te self%
emplo!ed@ to ens:re tat te proposed work metod is safe.
&raining9
'll operati<es m:st be gi<en specific instr:ctions on te s!stem of work to be :sed in eac case. )election ma! be
reA:ired of operati<es wo a<e experience of te work and are p!sicall! fit.
Risk Re<Assessment Date............................. Site )anager=s Comments9
0
2e3 Machinery Risk 1ssessment 7 e&ample +
Machine No Model Manufacturer Risk
1ssessment no
Model No 8ther Department /D
Hazards
Hazard 9es No Hazard 9e
s
No
,rapping Electroc:tion
Impact >ress:re
Contact *ot8Cold
Entanglement .ire
ECection (ter
5ho mi!ht 0e
harmed?
(perati<es Cleaners Maintenance Disitors (ters
Guarding
Fixed Guards Interlocked
Movable
Guards
Adjustable
guards
Fi&ed Distance
!uard
'deA:ate
Enclos:re of
dri<es and motors
.itted to macine .itted to macine .itted to macine
Closed to r:n Readil!
adC:stable
)ec:rel! fixed
)ec:rel! fixed in
position
+esign (E wit
positi<e switces
B rob:st
>re<ent
ECection
>re<ents access to
danger =one
,ool reA:ired to
remo<e
)afe to open Maintained (E ,ool to remo<e
Maintained (E Maintained (E
Controls /Warnings/ Instructions /Training
Controls Instruction/
Training
Area
Clearly
identifed
Shrouded
start
Warning
signs
Lighting OK
Function clear Warning
device
Signs clear Stability OK
Easy to use Isolator
nearby
Safety sheet
OK
Ventilation OK
Eergency
sto!
Isolator
loc"able
SOP
availa
ble
LEV needed
#achine sto!s
o"
$erit
re%uired
Training OK Access
operator
s
Sa&e at sto! Seating
needed
Access
mainten
ance
1ction Re"uired
3
S!"IT# F"$%&
C#
"ISI'%A( "IS) *S x
F+
(7 :o0 #afety 1nalysis Form
>6? SA#E&7 A%A'7S$S
#ob; +ate;
+epartment; Carried o:t b!;
+escription of Cob;
-egal reA:irements and g:idance
,ask steps *a=ards ConseA:ence
8-ikeliood
)e<erit! Risk
- F )
Controls
)afe s!stem of work
#ob Instr:ction
,raining reA:irements
Reie! date9
4
) 7 %ssential elements of a permit7to7;ork form
1 >ermit ,itle " >ermit No
$ #ob ,itle
& >lant identification
0 +escription of 6ork
3 *a=ard Identification
4 >reca:tions necessar! 4 )ignat:res
5 >rotecti<e EA:ipment
7 ':tori=ation
19 'cceptance
11 Extension8)ift ando<er
1" *and back
1" Cancellation
5
* 7 1n e&ample of a set of C8#HH assessment forms
C6SHH 1 < DE&A$'S 6# S8?S&A%CES 8SED 6R S&6RED
Name of Manager; GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG
Name of +epartment8'reaHGGGGGGGGGGGGGGGGGGGGGGGGGGG..
S8?S&A%CE DE&A$'S
1. Information from te label
,rade name;GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG
Man:fact:rerIs name;GGGGGGGGGGGGGGGGGGGGGGGGGGG..
Names of an! cemical constit:ents listed;GGGGGGGGGGGGGGGGGG.
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG.
*a=ard marking % weter corrosi<e@ irritant@ armf:l@ toxic@ <er! toxicGGGGGGG.
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG..
RI)E) >rases noted on label 1e.g. *armf:l in contact wit skin2
GGGGGGGGGGGGGGGG.....................................................................................
...............................................................................................................................................
)afet! >rases noted on labels 1e.g. a<oid contact wit skin2
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG........
...............................................................................................................................................
>REC'/,I(N) noted on label 1e.g. /se in well <entilated area2GGGGGGGGG
....GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG.
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG.
". *a<e !o: got a *ealt B )afet! +ata )eet for tis prod:ct? JE)8N(
DE&A$'S 6# 8SE
$. 6at it is :sed for?.............................................................................................................
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG
&. B! wom?............................................................................................................................
0. *ow often?..........................................................................................................................
3. 6ere?................................................................................................................................
4. 6at C(N,R(- meas:res 1preca:tions2 are :sed? 1E.g. local <entilation@ goggles@
respirator@ protecti<e glo<es. etc.2GGGGGGGGGGGGGGGGGGGGGGG..
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG.....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG.
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG.GG...
5. Is it 'B)(-/,E-J E))EN,I'- to keep8:se tis s:bstance? JE)8N(
7. Can it be +I)>()E+ (. N(6? JE)8N(
7
C6SHH / % ASSESS)E%& 6# A S8?S&A%CE
1. Name of s:bstance;GGGGGGGGGGGGGGGGGGGGGGGGGGGG.........
". ,e process or description of Cob were te s:bstance is :sedGGGGGGGGGG.......
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG........
$. -ocation of te process were s:bstance is :sedGGGGGGGGGGGGGGGG.....
&. *ealt B safet! information on s:bstance;
a2 *a=ards to ealt;GGGGGGGGGGGGGGGGGGGGGGGGGGGG........
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG........ ......
GGGGGG.GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG.
b2 >reca:tions reA:ired;GGGG.GGGGGGGGGGGGGGGGGGGGGGG.....
GG.GGGG.GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG.......
GGGG.GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
GG.GGGG.GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG......
GG.GGGG.GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG......
0. N:mber of persons exposed;GGGGGGGGGGGGGGGGGGGGGGGGG.....
3. .reA:enc! and d:ration of expos:re;GGGGGGGGGGGGGGGGGGGGGG...
4. Control meas:res tat are in :se;GGGGGGGGGGGGGGGGGGGGGGG.....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
5. ,e assessment@ an e<al:ation of te risks to ealt;GGGGGGGGGGGGGGG..
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG....
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG...
7. +etails of steps to be taken to red:ce te expos:re;GGGGGGGGGGGGGGG...
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG...
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG...
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG...
GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG...
19. 'ction to be taken b! 1name2 ;GGGGGGGGGGGGGGGG1+ate2;GGGGG....
11. +ate of next assessment8re<iew; .....................
1". Name and position of person making tis assessment; ...................................................
1$. +ate of assessment; ................................
+ 7 %&ample of a 5orkstation #elf 1ssessment
Checklist
%ame Department9 Date9
,e completion of tis cecklist will enable !o: to carr! o:t a self%assessment of !o:r own workstation. Jo:r
<iews are essential in order to enable :s to acie<e o:r obCecti<e of ens:ring !o:r comfort and safet! at
work. >lease circle te answer tat best describes !o:r opinion@ for eac of te A:estions listed. ,e form
so:ld be ret:rned toGGGGGGGGGGas soon as it as been completed.
Enironment
1. Lighting
+escribe te ligting at !o:r :s:al workstation.
'bo:t rigt ,oo brigt ,oo dark
+o !o: get distracting reflections on !o:r screen?
Ne<er )ometimes Constantl!
6at control do !o: a<e o<er local ligting?
.:ll control )ome control No control
2. Temperature and humidity
't !o:r workstation@ is it :s:all!;
Comfortable ,oo warm ,oo cold?
Is te air aro:nd !o:r workstation;
Comfortable ,oo dr!?
3. Noise
're !o: distracted b! noise from work eA:ipment?
Ne<er (ccasionall! Constantl!
4. Space
+escribe te amo:nt of space aro:nd !o:r workstation.
'deA:ate InadeA:ate
#-rnit-re
5. Chair
Can !o: adC:st te eigt of te seat?
Jes 8 No
Can !o: adC:st te eigt and angle of te backrest?
Jes 8 No
Is te cair stable?
Jes 8 No
+oes it allow mo<ement?
Jes 8 No
Record 1contin:ed2
#-rnit-re 1contin:ed2
Chair 1contin:ed2
Is te cair in a good state of repair?
Jes 8 No
If !o:r cair as arms@ do te! get in te wa!?
Jes 8 No
6. Desk
Is te desk s:rface large eno:g to allow !o: to place all !o:r eA:ipment were !o: want
it?
Jes 8 No
Is te eigt of te desk s:itable?
Jes 8 ,oo ig 8 ,oo low
+oes te desk a<e a matt s:rface 1non%reflectant2?
Jes 8 No
7. Footrest
If !o: cannot place !o:r feet flat on te floor wilst ke!ing@ as a footrest been s:pplied?
Jes 8 No
8. Document holder
If it wo:ld be of benefit to :se a doc:ment older@ as one been s:pplied?
Jes 8 No
If !o: a<e a doc:ment older@ is it adC:stable to s:it !o:r needs?
Jes 8 No
Display S+reen E@-ipment
9. Display screen
Can !o: easil! adC:st te brigtness and te contrast between te caracters on screen and
te backgro:nd?
Jes 8 No
+oes te screen tilt and swi<el freel!?
Jes 8 No
Is te screen image stable and free from flicker?
Jes 8 No
Is te screen at a eigt@ wic is comfortable for !o:?
Jes 8 No

10. Keyboard
Is te ke!board separate from te screen?
Jes 8 No
Record 1contin:ed2
Display S+reen E@-ipment (+ontin-ed)
Keyboard (continued)
Can !o: raise and lower te ke!board eigt?
Jes 8 No
Can !o: easil! see te s!mbols on te ke!s?
Jes 8 No
Is tere eno:g space to rest !o:r ands in front of te ke!board?
Jes 8 No
11. Software
+o !o: :nderstand ow to :se te software?
Jes 8 No
12. Training
*a<e !o: been trained in te :se of !o:r workstation?
Jes 8 No
*a<e !o: been trained in te :se of software?
Jes 8 No
If !o: were to a<e a problem relating to displa! screen work@ wo:ld !o: know te
correct proced:res to follow?
Jes 8 No
+o !o: :nderstand te arrangements for e!e and e!esigt tests?
Jes 8 No
Any other +ommentsA
1$
< 7 %&ample of a Noise 1ssessment Record Form
Name of Department= Date of #ur.ey=
o;er %&posure 1ction e.el'
() d*+ daily or ,ee"ly
>pper 1ction e.el'
(5 d*+ daily or ,ee"ly
Peak Pressure'
135 d*-C./130d*-C.
5orkplace
Num0er of
Persons
%&posed
Noise
e.el
2e"3
dB213
Daily
%&posure
Period
%P?d
dB213
Peak Pressure
dB2C3
Comments
@eneral Comments=
/nstrument >sed= Date of ast Cali0ration=
#i!nature= Position= Date=
1&
A 7 %&ample of a 5orkplace /nspection Report
Form
Wor"!lace Ins!ection Cover Sheet
Name of
Compan!8(rgani=ation
6ork area co<ered b!
tis Inspection
'cti<it! carried o:t in
work place
>erson carr!ing o:t
inspection
1>-E')E >RIN,2
+ate of
Inspection
(See Appendix 4.0 $nspe+tion Che+klist and Appendix 2.1 for haBard +he+klist)
6"serations
-ist a=ards@ :nsafe practices and good
practices
:riority;
risk
(HC)C')
A+tions to "e taken (if
any)
-ist all immediate and
longer%term actions
reA:ired
&ime S+ale
Immediate
1 week etc
10
B 7 5orkplace /nspection Checklist
:RE)$SES
1
*ork at Height -adders8step Rigt eA:ipment for te Cob?
ladders -e<el base?
Correct angle?
)ec:red at top and bottom?
EA:ipment in good condition?
Reg:larl! inspected
6orking ):itable for te task
platforms8 >roperl! erected?
Good access?
temporar! Maintained and inspected
scaffolds
/se of mobile ):itable for task?
ele<ating work
platforms
(perators properl! trained?
>roperl! maintained
"
A++ess 'ccess wa!s 'deA:ate for people@ maciner! and work in
progress?
/nobstr:cted?
>roperl! marked?
)tairs in good condition?
*andrails pro<ided?
*o:sekeeping ,id!@ clean@ well organi=ed?
.looring E<en and in good condition?
*orking
Enironment
Non%slipper!?
Comfort 8ealt Crowded?
,oo ot8cold? Dentilation?
*:midit!? +:st!? -igting?
Cleaning )lip risk controlled?
*!gienic conditions
Noise Normal con<ersation possible?
Noise assessment needed8not needed?
Noise areas designated?
Ergonomics ,asks reA:ire :ncomfortable post:res or
actions?
.reA:ent repetiti<e actions accompan!ing
m:sc:lar strain?
Dis:al displa! 6orkstation assessments needed8not needed
:nits Cairs adC:stable8comfortable8maintained
properl!?
Cables properl! controlled?
-igting (E? No glare?
13
& *elfare
,oilets 86asing 6asing and toilet facilities satisfactor!?
Eept clean@ wit soap and towels8
'deA:ate canging facilities
Eating facilities Clean and adeA:ate8Means of eating food?
Rest room
.or pregnant or n:rsing moters
Eept clean?
.irst aid
):itabl! placed and pro<isioned?
'ppointed person?
,rained first aider?
Correct signs and notices?
E!e was bottles as necessar!?
0 Seri+es
Electrical
eA:ipment
>ortable eA:ipment tested?
-eads tid! not damaged?
.ixed installation inspected
Gas EA:ipment ser<iced ann:all!?
6ater *ot and cold water pro<ided?
+rinking water pro<ided?
3 #ire pre+a-tions
.ire
exting:isers
$n place? .:ll? Correct t!pe?
Maintenance contract?
.ire instr:ctions >osted :p?
Not defaced or damaged?
.ire alarms .itted and tested reg:larl!?
Means of 'deA:ate for te n:mbers in<ol<ed?
escape8 .ire /nobstr:cted?
exits Easil! opened?
>roperl! signed?
Means of 'deA:ate for te n:mbers in<ol<ed?
escape8 .ire /nobstr:cted?
exits Easil! opened?
>roperl! signed?
14
:'A%& A%D S8?S&A%CES
4 *ork -ifting ,oro:gl! examined?
E@-ipment eA:ipment >roperl! maintained?
)lings etc properl! maintained?
(perators properl! trained?
>ress:re 6ritten scemes for inspection?
s!stems )afe working press:re marked?
>roperl! maintained?
)arps )afet! kni<es :sed?
Eni<es8needles8glass properl!
:sed8disposed of?
Dibration 'n! <ibration problems wit and eld
maciner! or wit wole bod! from <eicle
seats etc?
,ools and Rigt tool for te Cob?
eA:ipment $n good condition?
Man:al Mo<ing excessi<e weigt?
andling 'ssessments carried o:t?
/sing correct tecniA:e?
Co:ld it be eliminated or red:ced?
5 )an-al D
)e+hani+al
Handling
Mecanical .orklifts and oter tr:cks properl!
andling maintained?
+ri<ers a:tori=ed and properl! trained?
>assengers onl! were specificall! intended
wit s:itable seat?
7 Eehi+les
(n site )peeding limits?
.ollowing correct ro:te?
>roperl! ser<iced?
+ri<ers a:tori=ed
Road risks ):itable <eicles :sed?
No :se of mobile pones wen dri<ing?
>roperl! ser<iced? )ced:les managed
properl!?
15
19 Dangero-s
.lammable
liA:ids and
gases
)tored properl!?
/sed properl!8minim:m A:antities in
workplace?
)o:rces of ignition?
Correct signs :sed?
s-"stan+es
11 HaBardo-s
Cemicals C()** assessments (E?
Expos:res adeA:atel! controlled?
+ata seet information a<ailable?
)pillage proced:re a<ailable?
>roperl! stored and separated as necessar!?
>roperl! disposed of?
s-"stan+es
Exa:st
<entilation
):itable and s:fficient?
>roperl! maintained?
Inspected reg:larl!?
:R6CED8RES
1"
Risk
assessments
Carried o:t? General and fire?
):itable and s:fficient?
1$ Safe systems
of
>ro<ided as necessar!?
Eept :p to date8
.ollowed
*ork
1&
:ermits to !ork
/sed for ig risk maintenance?
>roced:re (E?
>roperl! followed?
10
:ersonal
:rote+tie
E@-ipment
Correct t!pe?
6orn correctl!?
Good condition?
13 Contra+tors
Is teir competence cecked toro:gl!?
're tere control r:les and proced:res?
're te! followed?
14 %oti+esC Signs
and :osters
Emplo!ersI
liabilit!
ins:rance
Notice displa!ed? In date?
*ealt and
)afet! law
poster
+ispla!ed?
)afet! )igns Correct t!pe of sign :sed8
)igns in place and maintained?
17
:E6:'E
15 Health
s-reillan+e
)pecific s:r<eillance reA:ired b! law?
)tress or fatig:e?
17 :eopleFs
"ehaio-r
're bea<io:r a:dits carried o:t?
Is bea<io:r considered in te safet!
programme?
"9 &raining and
s-perision
):itable and s:fficient?
Ind:ction training?
Refreser training?
"1 Appropriate
a-thoriBed
person
Is tere a s!stem for a:tori=ing people for
certain special tasks like permits to work@
dangero:s maciner!@ entr! into confined
spaces?
"" Eiolen+e
'n! <iolence likel! in workplace?
Is it controlled?
're tere policies in place
"$ Espe+ially at
risk
+ategories
Jo:ng persons Emplo!ed?
)pecial risk assessments?
New or
expectant
moters
Emplo!ed?
)pecial risk assessments?
"9
G < ACC$DE%&;$%C$DE%& RE:6R&
IN#/RE+ >ER)(N; GGGGGGGGGGGG.+ate of 'ccident; .....8.... 8"9 ,imeGGG.am8pm
>()I,I(N; GGGGGGGGGGGGGGGG>lace of 'ccident; GGGGGGGGGGGGGG.
+E>'R,MEN,; GGGGGGGGGGGGGG +etails of InC:r!; GGGGGGGGGGGGGG....
In<estigation carried o:t b!; GGGGGGGGG..GGGGGGGGGGGGGG............................
>osition; GGGGGGGGG.. Estimated 'bsence; GGGGGGGGGGGGG..............
?rief details of A++ident (' detailed report togeter wit diagrams@ potograps and an! witness statements
so:ld be attaced were necessar!. >lease complete all details reA:ested
o<erleaf.2
$mmediate Ca-ses 8nderlying or Root Ca-ses
Con+l-sions 1*ow can we pre<ent tis kind of incident8accident occ:rring again?2
'ction to be taken; GGGGGGGGGGGGGCompletion +ate;.... 8......8"9
>lease ens:re tat an accident in<estigation and report is completed and forwarded to >ersonnel
witin &5 o:rs of te accident occ:rring.
Remember tat accidents in<ol<ing maCor inC:ries or dangero:s occ:rrences a<e to be notified
immediatel! b! telepone to te local a:torit!.
)ignat:re of Manager making Report; GGGGGGGGGGGCopies; >ersonnel Manager
*ealt B )afet! Manager
+ate;.....8...... 8"9 >a!roll Controller
IN#/RE+ >ER)(N; ):rname GGGGGGG.........orenames GGGGGG..GGGG............
Male8.emale
*ome address GGGGGGGGGGGGGGGGGGGGG............................ 'geGGGG
Consent to sare tis information wit )afet! Representati<es
)ignat:re of InC:red >erson............................................+ate.......8......8....."9...
Emplo!ee 'genc! ,emp Contractor Disitor Jo:t ,rainee 1,ick one
"1
box2
(ind of A++ident Indicate wat kind of accident led to te inC:r! or condition 1tick one box2
Contact wit mo<ing InC:red wilst andling +rowning or Contact wit electricit! or
maciner! or material lifting or asp!xiation an electrical discarge
being macined 1 2 G 10
)tr:ck b! mo<ing )lip@ trip or fall on Expos:re to or InC:red b! an animal
incl:ding fl!ing@ or same le<el contact wit armf:l
falling obCect / 3 1H
11
)tr:ck b! mo<ing .all from eigt Expos:re to fire Diolence
<eicle 0 indicate approx. 4 11
12
+istance of fallGGGmtrs
)tr:ck against
someting fixed ,rapped b! someting Expos:re to an (ter kind of
or stationar! 1 collapsing or o<ert:rning 5 explosion 1/ accident
13
+etail an! maciner!@ cemicals@ tools etc. in<ol<ed
A++ident first reported to ; Name GGGGGGGGGGGGGG..
>osition B +eptGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG..
.irst 'id8medical attention b!; .irst 'ider Name GGGGGGGG+ept GGGGGGGGGG.
+octor Name GGGGGGG...............................................
Medical centre GGGGGGGG*ospitalGGGGGGGGG.
*$&%ESSES
Name >osition B +ept )tatement obtained 1!es8no2
'ttac all statements taken
GGGGGGGGGGG .GGGGGGGGGGGGGGGG GGGGGGGG !es8no
GGGGGGGGGGG .GGGGGGGGGGGGGGGG GGGGGGGG !es8no
GGGGGGGGGGG .GGGGGGGGGGGGGGGG GGGGGGGG !es8no
GGGGGGGGGGG .GGGGGGGGGGGGGGGG GGGGGGGG !es8no
.or (ffice :se onl!
If rele<ant; +ate reported to Enforcing ':torit! a2 b! telepone ....8G...8"9
b2 b! internet ....8......8"9
c2 on form ."095 G.8G..8"9
+ate reported to Compan! Ins:rers G..8G..8"9
""
6ere te Recommendations Effecti<e? Jes8No
If No sa! wat f:rter action so:ld be taken.
"$
1H < )an-al Handling of 'oads9 Assessment
'' 7 Manual Handlin! Risk 1ssessment
)an-al Handling Risk Assessment Employee +he+klist
&ask Des+ription Employees $D %o
Risk #a+tors
A. &ask Chara+teristi+s 7es;%o Risk 'eel C-rrent Controls
H ) '
1. -oads eld awa! from tr:nk?
". ,wisting?
$. )tooping?
&. Reacing :pwards?
0. Extensi<e <ertical mo<ements?
3. -ong carr!ing distances?
)an-al Handling of 'oads9 Assessment Che+klist
Se+tion A < :reliminary
&ask des+ription9
#a+tors "eyond the limits of the g-idelinesA
$s an Assessment neededA
(i.e. is there a potential risk of inI-ryC and are the
fa+tors "eyond the limits of the g-idelinesA)
7es ; %o
$f J7ES J+ontin-e. $f J%6= the assessment need go no f-rther.
&asks +oered "y this assessment
(detailed des+ription)9
'o+ations9
:eople inoled9
Date of assessment9
Diagrams and other information9
Se+tion ? See separate sheet for detailed analysis
Se+tion C 6erall assessment of the risk of inI-ryA 'o! ; )edi-m ; High
Se+tion D Remedial a+tion needed9
Remedial steps that sho-ld "e takenC in priority order9
a
"
+
d
e
f
g
h
Date "y !hi+h a+tion sho-ld "e taken9
Date for reassessment9
Assessor=s name9 Signat-re9
"&
4. )tren:o:s p:sing or p:lling?
5. /npredictable mo<ements of loads?
7. Repetiti<e andling operations?
19. Ins:fficient periods of rest8reco<er!?
11. *ig work rate imposed?
?. load +hara+teristi+s
1. *ea<!?
". B:lk!?
$. +iffic:lt to grasp?
&. /nstable8:npredictable?
0. *armf:l 1sarp8ot2?
C. *ork enironment +hara+teristi+s
1. >ost:ral constraints?
". .loor s:itabilit!?
$. E<en s:rface?
&. ,ermal8:midit! s:itabilit!?
0. -igting s:itabilit!?
D. $ndiid-al +hara+teristi+s
1. /n:s:al capabilit! reA:ired?
". *a=ard to tose wit ealt problems?
$. *a=ard to pregnant workers?
&. )pecial information8training reA:ired?
An, -urt.er action needed/ #es/&o
Details9
"0
'(7 %&ample $re #afety Maintenance Checklist
+ fre sa&ety aintenance chec"list can be used as a eans o& su!!orting
your fre sa&ety !olicy1 2his e3a!le list is not intended to be
co!rehensive and should not be used as a substitute &or carrying out a
fre ris" assessent1
4ou can odi&y the e3a!le ,here necessary5 to ft your !reises and
ay need to incor!orate the recoendations o& anu&acturers and
installers o& the fre sa&ety e%ui!ent/systes that you ay have
installed in your !reises1
+ny tic"s in the grey bo3es should result in &urther investigation and
a!!ro!riate action as necessary1 In larger and ore co!le3 !reises you
ay need to see" the assistance o& a co!etent !erson to carry out soe
o& the chec"s1
Source' 6e!artent &or Counities and 7ocal 8overnent Fire Sa&ety 8uides
7es %o %;A Comments
Daily Che+ks (not normally re+orded)
Escape Ro:tes
Can all fire exits be opened immediatel! and
easil!?
're fire doors clear of obstr:ctions?
're escape ro:tes clear?
.ire warning s!stems
Is te indicator panel sowing Knormal?
're wistles@ gongs or air orns in place?
Escape ligting
're l:minaries and exit signs in good condition
and :ndamaged?
Is emergenc! ligting and sign ligting working
correctl!?
.ire figting eA:ipment
're all fire exting:isers in place?
're fire exting:isers clearl! <isible?
're <eicles blocking fire !drants or access to
tem?
*eekly +he+ks
Escape ro:tes
"3
7es %o %;A Comments
+o all emergenc! fastening de<ices to fire exits
1p:s bars and pads@ etc.2 work correctl!?
're external ro:tes clear and safe?
*eekly +he+ks continued
.ire warning s!stems
+oes testing a man:al call point send a signal to
te indicator panel? 1+isconnect te link to te
recei<ing centre or tell tem !o: are doing a
test.2
+id te alarm s!stem work correctl! wen
tested?
+id staff and oter people ear te fire alarm?
+id an! linked fire protection s!stems operate
correctl!? 1e.g. magnetic door older released@
smoke c:rtains drop2
+o all <is:al alarms and8or <ibrating alarms and
pagers 1as applicable2 work?
+o <oice alarm s!stems work correctl!? 6as
te message :nderstood?
Escape ligting
're carging indicators 1if fitted2 <isible?
.irefigting eA:ipment
Is all eA:ipment in good condition?
'dditional items from man:fact:rers
recommendations.
)onthly +he+ks
Escape ro:tes
+o all electronic release mecanisms on escape
doors work correctl!? +o te! Kfail safe in te
open position?
+o all a:tomatic opening doors on escape
ro:tes Kfail safe in te open position?
're fire door seals and self%closing de<ices in
good condition?
+o all roller s:tters pro<ided for fire
compartmentation work correctl!?
're external escape stairs safe?
+o all internal self%closing fire doors work
correctl!?
Escape ligting
+o all l:minaries and exit signs f:nction
correctl! wen tested?
*a<e all emergenc! generators been tested?
1Normall! r:n for one o:r.2
.ire figting eA:ipment
Is te press:re in Kstored press:re fire
exting:isers correct?
"4
7es %o %;A Comments
'dditional items from man:fact:rers
recommendations.
&hree<monthly +he+ks
General
're an! emergenc! water tanks8ponds at teir
normal capacit!?
're <eicles blocking fire !drants or access to
tem?
'dditional items from man:fact:rers
recommendations.
Six<monthly +he+ks
General
*as an! fire figting or emergenc! e<ac:ation
lift been tested b! a competent person?
*as an! sprinkler s!stem been tested b! a
competent person?
*a<e te release and closing mecanisms of
an! fire%resisting compartment doors and
s:tters been tested b! a competent person?
.ire warning s!stem
*as te s!stem been cecked b! a competent
person?
Escape ligting
+o all l:minaries operate on test for one tird of
teir rated <al:e?
'dditional items from man:fact:rers
recommendations.
Ann-al +he+ks
Escape ro:tes
+o all self%closing fire doors fit correctl!?
Is escape ro:te compartmentation in good
repair?
Escape ligting
+o all l:minaries operate on test for teir f:ll
rated d:ration?
*as te s!stem been cecked b! a competent
person?
.ire figting eA:ipment
*as all fire figting eA:ipment been cecked b!
a competent person?
)is+ellaneo-s
*as an! dr!8wet rising fire main been tested b!
a competent person?
"5
7es %o %;A Comments
*as te smoke and eat <entilation s!stem
been tested b! a competent person?
)is+ellaneo-s contin:ed
*as external access for te fire ser<ice been
cecked for ongoing a<ailabilit!?
*a<e an! fire%figters switces been tested?
*as te fire !drant b!pass flow <al<e control
been tested b! a competent person?
're an! necessar! fire engine direction signs in
place?
"7
1$% %&ample Fire Risk 1ssessment Record of #i!ni$cant
Findin!s
Risk 1ssessment 6 Record of si!ni$cant $ndin!s
#ire Risk Assessment Re+ord of signifi+ant findings
Risk assessment for Assessment -ndertaken "y
Compan! +ate
'ddress Completed b!

)ignat:re
)eet n:mber .loor8area /se
Step 1 < $dentify fire haBards
So-r+es of ignition So-r+es of f-el So-r+es of oxygen
Step / :eople at risk
Step 0 Eal-ateC remoeC red-+e and prote+t from risk
1$.12 E<al:ate te risk
of te fire occ:rring
1$."2 E<al:ate te risk to
people from a fire starting
in te premises
1$.$2 Remo<e and red:ce
te a=ards tat ma!
ca:se a fire
1$.&2 Remo<e and red:ce
te risks to people
from a fire
Assessment reie!
'ssessment re<iew date Completed b! )ignat:re
Reie! o-t+ome (!here s-"stantial +hanges hae o++-rred a ne! re+ord sheet sho-ld "e -sed)
-1. 2he ris" assessent record o& signifcant fndings should re&er to other !lans5 records or other docuents as
necessary1
-2. 2he in&oration in this record should assist you to develo! an eergency !lan9 coordinate easures ,ith
other :res!onsible !ersons; in the building9 and to in&or and train sta< and in&or other relevant !ersons1
$9
$1
'* 7 Construction /nspection Report Form
Constr-+tion $nspe+tion Report
1. Name and address of person for wom inspection was carried o:t.
". )ite address. $. +ate and time of inspection.
&. -ocation and description of place of work or work eA:ipment inspected.
0. Matters wic gi<e rise to an! ealt and safet! risks.
3. Can work be carried o:t safel!? Jes 8 No
4. If not@ name of person informed.
5. +etails of an! oter action taken as a res:lt of matters identified in 0 abo<e.
7. +etails of an! f:rter action considered necessar!.
19. Name and position of person making
te report.
11. +ate and time report anded o<er.
1". Name and position of person
recei<ing report.
C*
/
#afety at ;ork
$"

Related Interests