SMS form - Contractors H&S return (Draft)

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Yes

  No

  N/A

• HSE Form - Monthly H&S return

  Yes

  No

  N/A

• Monthly Health and Safety Return

  Yes

  No

  N/A

INFO REQUIRED

• ANSWER

  Yes

  No

  N/A

• Contractor name:

• Date:

  Date

• Number of employees:

• Number of sub-contracted employees used:

• Number of man hours worked on OHH projects:

RIDDOR data (all company site/clients):

• Total number of accidents/incidents recorded:

• Number of Major accidents:*

• Number of over-3-day accidents:*

  Yes

  No

  N/A

• Number of cases of occupational disease:*

  Yes

  No

  N/A

• Number of dangerous occurrences:*

• Number of near-misses (or non-loss incidents) recorded:

Insurance and enforcement data:

• Active (ongoing) insurance claims:*

  Yes

  No

  N/A

• Active (ongoing) enforcement action/interventions:*

  Yes

  No

  N/A

Ongoing training data:

• Title of toolbox talk provided:

• Number of employees undertaking toolbox talk:

• (Please provide signature sheet)

  Yes

  No

  N/A

• Other H&S training provided this month:

• (title of training and names/role of persons receiving training)

  Yes

  No

  N/A

• NB * - please provide brief details – further info may be requested