Title Page
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Site Location
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Description of work to be carried out
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Customer Name
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Conducted on
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Assessment carried out by
1 - Site Induction
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1.1 - Completed a site induction including H&S
2 - High Risk Process Evaluation
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2.1 - is the work are a confined space?
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Please ensure the correct permit permit is issued for this type of work.
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2.2 - Are you undertaking Hot Work? (Grinding, cutting, welding and in some cases soldering)
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Please ensure you have the correct permit type and a suitable fire extinguisher to hand. Ensure you follow the customers fire watch procedure.
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2.3 - Are you working on live electricity?
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Please ensure you have the correct permit type for this work.
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2.4 - Are you working at heights? (Using steps, ladders, platforms, MEWP's....)
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Please ensure you have the correct permit for this work and any licences required for the equipment to be used.
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2.5 - Are you working on high pressure air lines?
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Please ensure that you have the correct permit for this work.
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2.6 - Does the work involve exposure or potential exposure to asbestos?
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This work should not be carried out without the correct PPE and and additional risk assessment and permit being carried out/issued.
3 - Workplace Hazards
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3.1 - Is there free access and exit routs to and from the workplace?
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Please state the observed hazards.
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3.2 - Is the work area free from danger of slips, trips and falls?
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Please state the observed hazards.
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3.3 - Is the work area free from obstructions and projections?
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Please state the observed hazards.
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3.4 - Is the work area free from falling or moving objects?
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Please state the observed hazards.
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3.5 - Is there enough room to work safely?
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Please state the reason for the lack of space.
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3.6 - Are dangers from traffic adequately controlled?
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Please state the observed hazards.
4 - Machinery Hazards
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4.1 - Has the machine been isolated in such a way that tit cannot be inadvertently operated?
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Please state what other protection methods have been put in place to justify this.
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4.2 - Have all electrical hazards been safely covered?
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Please state why not.
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4.3 - Can the task be carried out without removing safety devises?
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Please state what other safety procedures have been put in place.
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4.4 - Are you adequately protected from extremely hot and cold machine parts?
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Please state what precautions have been put in place to avoid exposure.
5 - Personal Exposure Hazards
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5.1 - Have all lifting tasks been safely addressed? (2 man lift, hoist etc......)
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Please state the reasons.
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5.2 - Are you adequately protected against excessive noise?
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Please state what additional precautions have been put in place to combat this.
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5.3 - Is there adequate light to safely carry out the task?
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Please request an additional lighting source.
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5.4 - Is the work area free from excessive vibration?
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What precautions have been put in place?
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5.5 - Is the work area free from exposure to high temperature and humidity?
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Please state what precautions have been put in place.
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5.6 - Is the work are free from exposure to low temperature?
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Please state what precautions have been put in place.
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5.7 - Do you have the correct tools to carry out the task safely and are they in a good state or repair?
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Please specify what is to be done to rectify this.
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5.8 - Is the work area free from exposure to harmful substances covered under COSHH?
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Please specify what additional precautions have been put in place.
6 - Administrative Controls
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6.1 - Do you have the correct PPE to complete the task?
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Ensure you attain the correct PPE before continuing with the task.
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6.2 - Has the operator been informed of the work to be carried out?
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Please specify who is aware of the work being done.
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6.3 - Do you have the required skills to complete the task?
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Please specify which parts of the task you are unable to complete and how this work is to be done.
7 - Comments
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Domino UK signature
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Customer signature
