Title Page
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Assessment / Site Reference Number
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Ref number
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Assessment date
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Activity / Item / Area
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Poeple At Risk
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Responsible Person
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Use of premises or site works taking place
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Assessor
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Review Date
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Monitoring Frequency
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Authorised by
Hazard Table
Sources of Ignition
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A. Smokers - Cigarettes, Matches, Lighters
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B. Naked flames - gas, open flame
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C. Electric, gas, cable strike
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D. Hot processes, welding, cutting, grinding
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E. Cooking equipment
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F. Lighting
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G. Arson
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H. Faulty / misused equipment / poor maintenance
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I. Reactive chemicals
Sources of Fuel
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J. Textiles / clothing
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K. Flammable liquids / solvents
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L. Plastics / rubber
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M. Waste materials
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N. Flammable gases
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O. Combustible construction materials - walls, floors, doors
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P. Combustible storage materials
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Q. Packaging materials
Sources of Oxygen
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R. Natural ventilation through doors / windows
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S. Explosion
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T. Oxidising chemicals
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U. Oxygen cylinders
Additional Sources
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V
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Degree of Risk
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W
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Degree of Risk
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X
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Degree of Risk
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Y
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Degree of Risk
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Z
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Degree of Risk
Potential for Fire to Spread
Conduction (Heating Through Materials)
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AA. Through Arcing High Voltage Equipment
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BB. Through piping / services
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CC. Doors (if not fire doors)
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DD. Hoarding
Convection (Hot Air Movement)
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EE. Stairs
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FF. Shafts / service ducts
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GG. Windows
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HH. Doors (open, wedged, not-self closing, damaged)
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II. Roof voids
Radiation
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JJ. Direct heat
Additional Hazards
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KK
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Degree of Risk
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LL
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Degree of Risk
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MM
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Degree of Risk
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NN
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Degree of Risk
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OO
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Degree of Risk
Monitoring Information
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Person carrying out the monitoring (print name)
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Department / Location
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Checked by
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Date
Control Measures
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Fire Fighting equipment - state Number, Types and Locations
- CO2
- WATER
- FOAM
- DRY POWDER
- WET CHEMICAL
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How many
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Location(s)
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How Many
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Location(s)
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How Many
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Location(s)
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How Many
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Location(s)
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How Many
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Location(s)
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Fire Detection and Warning System - State Numbers, Types and Locations
- Smoke Detector
- Carbon Monoxide Detector
- Heat Detector
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How Many
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Location(s)
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How Many
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Location(s)
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How Many
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Location(s)
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Notices/ Records/ Procedures
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Escape Routes
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Maintenance and Testing of Equipment
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Building Design – Features of Escape Routes
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Housekeeping / Storage of Waste and Materials
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Additional Control Measures
Further Actions Required
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1.Action
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Responsibility
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Date
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Action
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Responsibility
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Date
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Action
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Responsibility
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Date
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Action
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Responsibility
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Date
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Action
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Responsibility
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Date
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Action
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