Title Page

  • Client / Site

  • Department

  • Location
  • Conducted on

  • Prepared by

  • Lone workers involved

  • Staff
  • Lone worker's name and role


  • Medical Fitness:<br>Is the Lone Worker subject to any medical condition that may place them at increased risk when working alone?

  • Supervision: What arrangements are in place to maintain contact with the lone worker?

  • Training & Competency : <br>Has necessary information, instruction, and training been given to the lone worker?

  • Training & Competency: Is the lone worker competent to carry out the work alone?

Location & Premises

  • Building security:<br>Is the building secure?

  • Access: <br>Is there a safe means of access/egress for the lone worker?

  • Emergencies: <br>Does the lone worker have access to emergency warning devices to raise the alarm in event of emergency e.g. fire alarm, motion sensors /manual device (panic alarms)?

  • First aid:<br>Are there arrangements are in place to deal with a situation where the lone worker becomes ill or has an accident?

  • Welfare facilities: <br>Is there adequate heating, lighting, access to drinking water and toilets?

Process/Work Activity

  • Select hazards identified in the work premises

  • Please specify hazards

  • Control/Preventive Measures

  • Documentation


  • Full Name and Signature of Inspector

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.