Asbestos Assessment form v1

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Job & Customer details

• Date

  Date
• Address
  Address

• Job ID

• Customer Name

• Surveyor Name

General Asbestos Assessment

• Is the customer aware of any known Asbestos or Asbestos Containing Materials installed, located, disturbed or other history in the property.

  Yes

  No

• Comments

• Do you or the customer have any reason to suspect Asbestos is in the property?

  Yes

  No

• Comments (if Asbestos/ACM in property state room and specific location)

• If present please select one or many of the following types of Asbestos/ACM which you believe May be present within the property

• AIB

  Off

  On

• Boiler Plinth

  Off

  On

• Cement

  Off

  On

• Floor coverings

  Off

  On

• Gaskets/Seals

  Off

  On

• Lagging

  Off

  On

• Textured Coating

  Off

  On

• Unknown

  Off

  On

• Other (please provide details)

• If present, what is the visual condition of the Asbestos material?

  Sound

  Unsound

• Could the location of the material result in accidental damage/disturbance if an installation goes ahead?

  Yes

  No

• Is Asbestos removal or a detailed asbestos survey required?

  Yes

  No

• As far as you can tell, please select the action that is required following this assessment?

• No Asbestos related work

  Off

  On

• Drilling

  Off

  On

• Sampling

  Off

  On

• Removal

  Off

  On

• Unknown

  Off

  On

• Please state how the installation can proceed if there is Asbestos in the property? (I.e. Boiler to be positioned in an alternative location)

Sign off

• Customer / Householder signature

  Sign

• Surveyor signature

  Sign

• Date

  Date