Title Page

  • Document No.

  • Premises Name

  • Client

  • Conducted on

  • Prepared by

  • Add drawing

  • Add drawing

Contact Details

  • Address
  • Contract Persons
  • Name

  • Tel.no.

  • Mob. no.

  • Email address

  • Title

  • If other. Place title in box below

Occupants

    Area
  • Business Hours

  • Staff day

  • Number

  • Staff Night

  • Number

  • Staff Sleeping

  • Number

  • Service Users day

  • Number

  • Service Users Night

  • Number

  • Service Users Sleeping

  • Number

  • Service Users Non-ambulant

  • Number

Fire Safety Measures

Fire alarm panel

  • Location

  • What type is it

  • Is it monitored

  • Provide contact details

  • Repeater panels
  • Is there a repeater panel in this area

  • Location

  • Notes

  • Fire exits
  • Location

  • Type of lock

  • Is there a key box

  • Manual call points
  • Location

  • Hydrants
  • Location

  • Flow

  • Pressure

  • Hyd no

Building Details

  • Height

  • Storeys

  • Construction

  • Roof

  • Add media

Vehicular Access

  • Are there any gates

  • Location

  • Are they locked

  • What are arrangements for opening gates

  • Are there any key codes

  • Codes

  • Are there any height restrictions

  • Itemise restriction

  • Preferred route

  • Add media

Services Oil

  • Is there an oil fired boiler house

  • Location

  • Oil tank location

  • Oil tank capacity in litres

  • Sketch

  • Add media

  • Notes

  • Is there automatic fire suppression above burner

  • Type

  • Notes

  • Add media

  • Add drawing

Services Gas

  • Is there a gas fueled boiler house

  • Location of boiler house
  • Location

  • Location of shut off
  • Location

  • Add media

  • Add drawing

  • Notes

  • Is there LPG on site

  • Location of LPG Tank
  • Add media

  • Add drawing

  • Location

  • Capacity

  • Location of shut offs
  • Add media

  • Add drawing

Services Electrical

    Shut off location
  • Location

  • Voltage

  • Add media

  • Add drawing

  • Notes

Hazardous Substance

Oxygen

  • UN Number 1234

  • Is there a tank

  • Location

  • Capacity

  • Add media

  • Add drawing

  • Oxygen cylinders UN No. 1234
  • Location

  • Size of cylinder

  • Number of cylinders

  • Add media

  • Add drawing

  • Notes

  • Nitrous oxide cylinders UN No
  • Location

  • Size of cylinder

  • Number of cylinders

  • Add media

  • Add drawing

  • Notes

  • Medical Air UN No.
  • Location

  • Size of cylinders

  • Number of cylinders

  • Add media

  • Add drawing

  • Other Hazardous Substances
  • Substance name

  • UN Number

  • Quantity

Salvage

    Item
  • Location

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.