• Document No.

Employer Details

  • Company name.

  • Workplace address (Including postcode)
  • Number of Employees.

  • Nature of business.

  • Insurers name:

  • Date.

  • Policy number:

  • Day of Month:

  • Expiry Month:

  • Expiry Year:

  • Main contact person.

  • Phone number.

  • Health and safety contact.

  • Email address.

  • T2000 Area/Dept Appraisal.

  • Type of work carried out by the learner at the workplace location.

  • CDA/LA Name.

Risk Banding

  • Risk Banding

  • Next Assessment due date

Authorisation of Placement

  • Fully approved.

  • Conditionally Approved (Subject to completion of Development Plan).

  • Unsatisfactory.

  • Authorising Signature.



  • Company

  • Review Type

  • Physical

  • Desktop Audit

  • Note to the HSE Advisor: Is there and action plan / reports of none-conformance linked to the company? If yes, give details below.


  • 1. Have there been any changes since the initial assessment? Eg relocation, ownership, name etc?

  • 2. Have the Health and Safety Policy / Risk Assessments been reviewed?

  • 3. Is there a sample of the documentation within the company file?

  • 4. Has the learner been involved in an accident in the workplace since training commenced?

  • 5. Has the learner been involved in a fire drill since the initial appraisal?

  • 6. Has the HSE Advisor received a tour of the workplace?

  • 7. Do suitable and sufficient control measures appear to be in place?

  • 8. Has the learner(s) received any other Health and Safety Training through the employer

  • Detail of action plan arising from the review (stating follow up / completion date)

The employer or their representative sign to agree this is an accurate record of assessment

  • Name & Job Title

  • To the Authorising Officer:
    It is recommended that the above named organisation should be regarded as:-
    Conditionally Approved. ( Subject to Completion of Development Plan)
    As a training provider of work experience / on the job training for Training 2000 Ltd.

  • HSE Advisor Signature.

H&S FM025 (a)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.