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STEP 1 – SITE INSPECTION (Risk Assessment form –Appendix A1)

Company name: Date of Inspection:

What are the Who might be What you should do What further action Who should be When should the When should the
hazards? harmed and how? immediately to is necessary in the responsible for this action start action end
correct the harm? future? action?
STEP 2 – ASSESS THE LEVEL OF RISK (Risk Assessment form –Appendix A2)

Hazards/ Risks and Control Measures

1. Description of Hazards / Risks 2. Risk Level 3. Control Measures

4. Other Details:
STEP 3 – MONITOR & REVIEW OF CONTROL / SUBMISSION (Risk assessment form – Appendix A3)


1. Are the control measures sufficient and effective in minimizing the Yes No
level of risk?

2. Will there be changes to the control measures? (if yes state period) Yes No

3. Will there be need for further control measures in future? Yes No

4. Will there be need for training of workers? (if yes, state training Yes No
type, or who and when

5. Will there be need to review this assessment in the future? (if yes, Yes No
state when)

Declaration / Submission

This activity will be conducted in accordance with this risk assessment, implementing the control measures outlined. Changed will be made to

Submitted by: Date:

Name and signature of Site Supervisor:

Step 4 –Health and safety policy (Risk Assessment Form-A4)

(Name of company)
This is the statement of general policy and arrangements for:
has overall and final responsibility for health sn safety
(Name of employer/Senior manager)
has day-to-day responsibility for ensuring this policy is put into practice
(member of staff)
Responsibility of: Statement of general policy Action /Arrangements (What are you going to
Name/Title do?)
Prevent accidents and cases of work-related ill health by managing the health and
safety risks I the work place
Provide clear instructions and information, and adequate training, o ensure
employees re competent to do their work
Engage and consult with employees on day-to-day heal and safety conditions
Implement emergency procedures- evacuation in case of fire and other significant
Maintain safety and healthy working conditions, provide and maintain plant ,
equipment and machinery, and ensure safe storage/use of substances

Signed: *(employer/Business Owner) Date

Indicate location where health and safety law is poster is

displayed. If not displayed indicate where it should be <indicate here>

Indicate if First-aid box is present. If yes where, if no,

indicate where it should be <indicate here>

Indicate if Accident book is present . if yes where, if no,

indicate where it should be. <indicate here>