Title Page

  • Conducted on

  • Prepared by

  • Location


  • Name of Site and Address
  • Name of Client or Client's site representative

  • Contract no:

  • Name of Assessor

  • Date of Assessment

The Infestation

  • Carry out a site Survey and provide document ref

  • Were environmental risks noted during the survey? Complete the remainder of this form if the answer is yes.

  • Is there a current rodent infestation?

  • Is the Infestation situated only indoors and will baits only be placed indoors?

  • Is there a significant risk to human health or animal health presented by a possible future infestation?

  • Do you intend to use permanent baiting?

  • If yes give reference to document showing justification

Risk Hierarchy

  • Why is it necessary to use a rodenticide at this site? Why cant the situation be resolved by other methods, such as improving hygiene and preventing rodent ingress to sensetive areas or traps?

  • If you intend to use Second generation anticoagulant rodenticides and not first generation explain why.

Sensetive areas

  • Record if the site is entirely, or contains part of, one of the designated sensitive areas listed in the advisory leaflet. If so, list any protected species that may be there


  • Give product name, active ingredient and HSE Authorization numbers for all products to be used


  • Provide a list of all the environmental risks you percieve to be present at this site

  • Provide a list of all the measures you will use during rodenticide application at the site to reduce the risks you have identified

Disposal of Carcasses

  • How often will you search for carcasses?

  • Will others on site also search for rodent carcasses?

  • What measures will you use to safely dispose of rodent carcasses?

Disposal of spent bait

  • How will you dispose of spent bait?


  • With due consideration to the information recorded above, can this treatment safely proceed without unacceptable damage to wildlife and the environment?


  • Add signature

  • Add signature

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.